Provider Demographics
NPI:1184777666
Name:SPINE AND SPORTS CHIROPRACTIC CARE OF CONNECTICUT, LLC
Entity type:Organization
Organization Name:SPINE AND SPORTS CHIROPRACTIC CARE OF CONNECTICUT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-269-3225
Mailing Address - Street 1:336 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2119
Mailing Address - Country:US
Mailing Address - Phone:860-693-8567
Mailing Address - Fax:
Practice Address - Street 1:220 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1949
Practice Address - Country:US
Practice Address - Phone:860-269-3225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2013-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03646OtherMEDICARE GROUP PIN
CTC03646OtherMEDICARE GROUP PIN
CTU95584Medicare UPIN