Provider Demographics
NPI:1518914639
Name:ADVANCED BACK& NECK CENTER
Entity Type:Organization
Organization Name:ADVANCED BACK& NECK CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUDEJ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DC
Authorized Official - Phone:203-878-8803
Mailing Address - Street 1:555 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-2635
Mailing Address - Country:US
Mailing Address - Phone:203-878-8803
Mailing Address - Fax:203-874-3945
Practice Address - Street 1:555 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-2635
Practice Address - Country:US
Practice Address - Phone:203-878-8803
Practice Address - Fax:203-874-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1033111N00000X
CT00764111N00000X
CT002136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty