Provider Demographics
NPI:1306022496
Name:PROHEALTH CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:PROHEALTH CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-432-7432
Mailing Address - Street 1:1127 TOLLAND TURNPIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-432-7432
Mailing Address - Fax:860-432-9049
Practice Address - Street 1:1127 TOLLAND TURNPIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042
Practice Address - Country:US
Practice Address - Phone:860-432-7432
Practice Address - Fax:860-432-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001726111N00000X
CT001722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03898OtherGROUP MEDICARE
ME432191999Medicaid
MEME1910OtherMEDICARE PROVIDER NUMBER
ME432191999Medicaid