Provider Demographics
NPI:1467667923
Name:PRIMARY SPINE & REHAB LLC
Entity Type:Organization
Organization Name:PRIMARY SPINE & REHAB LLC
Other - Org Name:CHIROPRACTIC HEALTH CENTER OF ENFIELD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SADOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-763-2225
Mailing Address - Street 1:143 HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-763-2225
Mailing Address - Fax:860-763-3161
Practice Address - Street 1:143 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-763-2225
Practice Address - Fax:860-763-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001310111N00000X
CT007813225100000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4198348Medicaid
CT77603OtherCONNECTICARE
CT41986348Medicaid
CTG2994212OtherOXFORD
CTG2994212OtherOXFORD
CTC03014Medicare UPIN