Provider Demographics
NPI:1093254500
Name:SPINE & SPORT FAIRFIELD LLC
Entity Type:Organization
Organization Name:SPINE & SPORT FAIRFIELD LLC
Other - Org Name:SOURCE OF STRENGTH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:SKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-522-4121
Mailing Address - Street 1:27 HALLEY CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-5557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 HALLEY CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-5557
Practice Address - Country:US
Practice Address - Phone:203-522-4121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1953111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty