Provider Demographics
NPI:1235156936
Name:PHYSICAL MEDICINE AND FAMILY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE AND FAMILY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:DERANEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-426-6334
Mailing Address - Street 1:24 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1124
Mailing Address - Country:US
Mailing Address - Phone:203-426-6334
Mailing Address - Fax:203-426-3070
Practice Address - Street 1:24 GLEN RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:CT
Practice Address - Zip Code:06482-1124
Practice Address - Country:US
Practice Address - Phone:203-426-6334
Practice Address - Fax:203-426-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001672111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty