Provider Demographics
NPI:1679667604
Name:GLASTONBURY OSTEOPATHIC, LLC
Entity Type:Organization
Organization Name:GLASTONBURY OSTEOPATHIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:SQUATRITO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-659-5999
Mailing Address - Street 1:59 SYCAMORE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4535
Mailing Address - Country:US
Mailing Address - Phone:860-659-5999
Mailing Address - Fax:860-633-9423
Practice Address - Street 1:59 SYCAMORE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4535
Practice Address - Country:US
Practice Address - Phone:860-659-5999
Practice Address - Fax:860-633-9423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH03470Medicare UPIN