Provider Demographics
NPI:1033162698
Name:CHIROPRACTIC ASSOCIATES OF BRIDGEPORT
Entity Type:Organization
Organization Name:CHIROPRACTIC ASSOCIATES OF BRIDGEPORT
Other - Org Name:CARPENTER CHIROPRACTIC ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-374-4393
Mailing Address - Street 1:4444 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1820
Mailing Address - Country:US
Mailing Address - Phone:203-374-4393
Mailing Address - Fax:203-371-8584
Practice Address - Street 1:4444 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1820
Practice Address - Country:US
Practice Address - Phone:203-374-4393
Practice Address - Fax:203-371-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT214111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004136174Medicaid
CTC00722Medicare ID - Type Unspecified