Provider Demographics
NPI:1851953475
Name:MID-COAST SPINE & SPORT LLC
Entity Type:Organization
Organization Name:MID-COAST SPINE & SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERGOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-357-4541
Mailing Address - Street 1:14 MARDEN RD
Mailing Address - Street 2:
Mailing Address - City:BOOTHBAY HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04538
Mailing Address - Country:US
Mailing Address - Phone:207-357-4541
Mailing Address - Fax:
Practice Address - Street 1:18 WEST ST
Practice Address - Street 2:
Practice Address - City:BOOTHBAY HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04538-1849
Practice Address - Country:US
Practice Address - Phone:207-357-4541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty