Provider Demographics
NPI:1790942654
Name:DR. BERT J. DAIGLE C.C.S.P,,P.A.
Entity Type:Organization
Organization Name:DR. BERT J. DAIGLE C.C.S.P,,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTHOL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-784-2049
Mailing Address - Street 1:1008 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5721
Mailing Address - Country:US
Mailing Address - Phone:207-784-2049
Mailing Address - Fax:207-784-8562
Practice Address - Street 1:1008 LISBON ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5721
Practice Address - Country:US
Practice Address - Phone:207-784-2049
Practice Address - Fax:207-784-8562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME017363OtherANTHEM
ME066855Medicare PIN
MET31526Medicare UPIN