Provider Demographics
NPI:1598258519
Name:CONNECTICUT SPORTS CLINIC LLC
Entity Type:Organization
Organization Name:CONNECTICUT SPORTS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-589-0226
Mailing Address - Street 1:129 CHURCH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2070
Mailing Address - Country:US
Mailing Address - Phone:203-589-0226
Mailing Address - Fax:
Practice Address - Street 1:129 CHURCH ST FL 1
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2026
Practice Address - Country:US
Practice Address - Phone:203-200-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2028261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174912125Medicaid