Provider Demographics
NPI:1205924529
Name:CAPITAL CITY CHIROPRACTIC PC
Entity type:Organization
Organization Name:CAPITAL CITY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRONDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-620-8291
Mailing Address - Street 1:66 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5837
Mailing Address - Country:US
Mailing Address - Phone:207-620-8291
Mailing Address - Fax:207-620-8292
Practice Address - Street 1:66 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5837
Practice Address - Country:US
Practice Address - Phone:207-620-8291
Practice Address - Fax:207-620-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty