Provider Demographics
NPI:1942477161
Name:STRATFORD CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:STRATFORD CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PESALE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-556-3074
Mailing Address - Street 1:2505 MAIN ST
Mailing Address - Street 2:STATIONHOUSE SQUARE
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5839
Mailing Address - Country:US
Mailing Address - Phone:203-386-9100
Mailing Address - Fax:
Practice Address - Street 1:2505 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5839
Practice Address - Country:US
Practice Address - Phone:203-386-9100
Practice Address - Fax:203-375-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000017Medicare PIN