Provider Demographics
NPI:1891922902
Name:PRECISION CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:PRECISION CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-284-9200
Mailing Address - Street 1:857 N MAIN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2465
Mailing Address - Country:US
Mailing Address - Phone:203-284-9200
Mailing Address - Fax:203-294-0410
Practice Address - Street 1:857 N MAIN STREET EXT
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2465
Practice Address - Country:US
Practice Address - Phone:203-284-9200
Practice Address - Fax:203-294-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001390111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350001353Medicare PIN