Provider Demographics
NPI:1093254880
Name:BACK TO MOTION SPORTS REHAB AND FITNESS
Entity Type:Organization
Organization Name:BACK TO MOTION SPORTS REHAB AND FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:VISCONTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-248-9989
Mailing Address - Street 1:435 WILLARD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2318
Mailing Address - Country:US
Mailing Address - Phone:860-665-0826
Mailing Address - Fax:860-665-0826
Practice Address - Street 1:435 WILLARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2318
Practice Address - Country:US
Practice Address - Phone:860-665-0826
Practice Address - Fax:860-665-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2055111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1679018600OtherSOLE PROPRIETOR NPI