Provider Demographics
NPI:1619160256
Name:GODFREY CHIROPRACTIC & REHABILIATION
Entity Type:Organization
Organization Name:GODFREY CHIROPRACTIC & REHABILIATION
Other - Org Name:GODFREY CHIROPRACTIC REHAB AND NUTRITION CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/SOLE PROPRIETER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EAMON
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:860-232-3277
Mailing Address - Street 1:220 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1949
Mailing Address - Country:US
Mailing Address - Phone:860-232-3277
Mailing Address - Fax:860-232-6277
Practice Address - Street 1:220 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1949
Practice Address - Country:US
Practice Address - Phone:860-232-3277
Practice Address - Fax:860-232-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350001378Medicare UPIN