1538571955 NPI number — ADVANCED BACK & WELLNESS CENTER LLC

Table of content: (NPI 1588697734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538571955 NPI number — ADVANCED BACK & WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED BACK & WELLNESS 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:
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:
1538571955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUTNAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06260-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-928-2292
Provider Business Mailing Address Fax Number:
860-928-0537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-928-2292
Provider Business Practice Location Address Fax Number:
860-928-0537
Provider Enumeration Date:
05/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BURNS
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
860-928-2292

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D100146044 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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