Provider Demographics
NPI:1902086010
Name:SCOT L. GOLDBERG, D.C. LLC
Entity Type:Organization
Organization Name:SCOT L. GOLDBERG, D.C. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-744-2663
Mailing Address - Street 1:180 OLD HAWLEYVILLE RD
Mailing Address - Street 2:UNIT 4
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-3044
Mailing Address - Country:US
Mailing Address - Phone:203-744-2663
Mailing Address - Fax:
Practice Address - Street 1:180 OLD HAWLEYVILLE RD
Practice Address - Street 2:UNIT 4
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-3044
Practice Address - Country:US
Practice Address - Phone:203-744-2663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350001235Medicare PIN
CTU53593Medicare UPIN