Provider Demographics
NPI:1861581225
Name:THE BOOTHBAY CHIROPRACTOR
Entity type:Organization
Organization Name:THE BOOTHBAY CHIROPRACTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BOUFFARD
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DC
Authorized Official - Phone:207-633-5500
Mailing Address - Street 1:18 WEST ST
Mailing Address - Street 2:
Mailing Address - City:BOOTHBAY HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04538-1849
Mailing Address - Country:US
Mailing Address - Phone:207-633-5500
Mailing Address - Fax:207-633-0805
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:207-633-5500
Practice Address - Fax:207-633-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1032111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9405Medicare ID - Type Unspecified
MEU59141Medicare UPIN