1467755900 NPI number — PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC

Table of content: (NPI 1467755900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467755900 NPI number — PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN & SPINE SPECIALISTS OF CONNECTICUT, 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:
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:
1467755900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 SAND PIT RD
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
DANBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06810-4032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-743-7246
Provider Business Mailing Address Fax Number:
203-792-3920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 W MAIN ST
Provider Second Line Business Practice Location Address:
BLDG 2
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-758-2523
Provider Business Practice Location Address Fax Number:
203-792-3920
Provider Enumeration Date:
12/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LEVI
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-743-7246

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  038785 , 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)





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