Provider Demographics
NPI:1174564942
Name:CONNECTICUT BACK CENTER LLC
Entity type:Organization
Organization Name:CONNECTICUT BACK CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:EISLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-872-6229
Mailing Address - Street 1:460 HARTFORD TPKE
Mailing Address - Street 2:SUITE B
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4845
Mailing Address - Country:US
Mailing Address - Phone:860-872-6229
Mailing Address - Fax:860-872-6252
Practice Address - Street 1:460 HARTFORD TPKE
Practice Address - Street 2:SUITE B
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4845
Practice Address - Country:US
Practice Address - Phone:860-872-6229
Practice Address - Fax:860-872-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03399Medicare PIN