Provider Demographics
NPI:1457021537
Name:REILLY, BEN C (DC)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:C
Last Name:REILLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1506
Mailing Address - Country:US
Mailing Address - Phone:860-579-4021
Mailing Address - Fax:
Practice Address - Street 1:645 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1506
Practice Address - Country:US
Practice Address - Phone:860-579-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor