Provider Demographics
NPI:1134372964
Name:CROMWELL CHIROPRACTIC CENTER, LLC
Entity type:Organization
Organization Name:CROMWELL CHIROPRACTIC CENTER, 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:M
Authorized Official - Last Name:SHORTELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-635-4455
Mailing Address - Street 1:28 SHUNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2454
Mailing Address - Country:US
Mailing Address - Phone:860-635-4455
Mailing Address - Fax:860-635-0499
Practice Address - Street 1:28 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2454
Practice Address - Country:US
Practice Address - Phone:860-635-4455
Practice Address - Fax:860-635-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001242111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004178035Medicaid
CT004178035Medicaid