Provider Demographics
NPI:1598706160
Name:MOORADIAN, MARY LAVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LAVIN
Last Name:MOORADIAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:LAVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:377 COLMAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3713
Mailing Address - Country:US
Mailing Address - Phone:860-444-6363
Mailing Address - Fax:860-443-3314
Practice Address - Street 1:377 COLMAN ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-3713
Practice Address - Country:US
Practice Address - Phone:860-444-6363
Practice Address - Fax:860-443-3314
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000593111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT7853Medicare UPIN
CT350000487Medicare ID - Type Unspecified