Provider Demographics
NPI:1043489297
Name:SOUTH STREET CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:SOUTH STREET CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:PORTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-794-1049
Mailing Address - Street 1:15 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-8147
Mailing Address - Country:US
Mailing Address - Phone:203-794-1049
Mailing Address - Fax:203-730-9721
Practice Address - Street 1:15 SOUTH ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-8147
Practice Address - Country:US
Practice Address - Phone:203-794-1049
Practice Address - Fax:203-730-9721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT487111N00000X
CT503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50SOUTHSTCT01OtherANTHEM BLUE CROSS/BLUE SH
CT50SOUTHSTCT01OtherANTHEM BLUE CROSS/BLUE SH