Provider Demographics
NPI:1942700364
Name:MODERN CHIROPRACTIC OF NEWINGTON LLC
Entity Type:Organization
Organization Name:MODERN CHIROPRACTIC OF NEWINGTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-667-8334
Mailing Address - Street 1:2301 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3206
Mailing Address - Country:US
Mailing Address - Phone:860-667-8334
Mailing Address - Fax:860-760-6456
Practice Address - Street 1:2301 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3206
Practice Address - Country:US
Practice Address - Phone:860-667-8334
Practice Address - Fax:860-760-6456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty