Provider Demographics
NPI:1962688036
Name:BLOOMFIELD CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:BLOOMFIELD CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-243-2142
Mailing Address - Street 1:11 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2343
Mailing Address - Country:US
Mailing Address - Phone:860-243-2142
Mailing Address - Fax:860-242-0274
Practice Address - Street 1:11 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2343
Practice Address - Country:US
Practice Address - Phone:860-243-2142
Practice Address - Fax:860-242-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001213111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001213CT01OtherBLUECROSS
CTU84097Medicare UPIN