1366744922 NPI number — O'MALLEY CHIROPRACTIC HEALTH CENTER, LLC

Table of content: (NPI 1366744922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366744922 NPI number — O'MALLEY CHIROPRACTIC HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
O'MALLEY CHIROPRACTIC HEALTH CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366744922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 BEAVER ROAD
Provider Second Line Business Mailing Address:
SUITE 2A
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-257-9400
Provider Business Mailing Address Fax Number:
860-257-7169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 BEAVER ROAD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-257-9400
Provider Business Practice Location Address Fax Number:
860-257-7169
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
O'MALLEY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
860-257-9400

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CT000731 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 519710 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 050000731CT01 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 682637 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".




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