Provider Demographics
NPI:1538571955
Name:ADVANCED BACK & WELLNESS CENTER LLC
Entity type:Organization
Organization Name:ADVANCED BACK & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-928-2292
Mailing Address - Street 1:21 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1906
Mailing Address - Country:US
Mailing Address - Phone:860-928-2292
Mailing Address - Fax:860-928-0537
Practice Address - Street 1:21 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1906
Practice Address - Country:US
Practice Address - Phone:860-928-2292
Practice Address - Fax:860-928-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100146044OtherMEDICARE GROUP PTAN