Provider Demographics
NPI:1528087749
Name:CENTRAL CONNECTICUT CHIROPRACTIC, PC
Entity type:Organization
Organization Name:CENTRAL CONNECTICUT CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMOSSI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-828-3435
Mailing Address - Street 1:36 CHAMBERLAIN HWY
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1921
Mailing Address - Country:US
Mailing Address - Phone:860-828-3435
Mailing Address - Fax:860-828-1203
Practice Address - Street 1:36 CHAMBERLAIN HWY
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1921
Practice Address - Country:US
Practice Address - Phone:860-828-3435
Practice Address - Fax:860-828-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000759111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02168Medicare ID - Type Unspecified