Provider Demographics
NPI:1154488815
Name:ANTONINO, CARLO (DC)
Entity Type:Individual
Prefix:DR
First Name:CARLO
Middle Name:
Last Name:ANTONINO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:CARLO
Other - Middle Name:
Other - Last Name:ANTONINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:259 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1402
Mailing Address - Country:US
Mailing Address - Phone:860-599-5551
Mailing Address - Fax:860-599-5595
Practice Address - Street 1:259 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1402
Practice Address - Country:US
Practice Address - Phone:860-599-5551
Practice Address - Fax:860-599-5595
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000799CT01111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor