Provider Demographics
NPI:1457343006
Name:WOODBURY CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:WOODBURY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:POGONOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-263-0400
Mailing Address - Street 1:264 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3407
Mailing Address - Country:US
Mailing Address - Phone:203-263-0400
Mailing Address - Fax:203-263-0090
Practice Address - Street 1:264 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3407
Practice Address - Country:US
Practice Address - Phone:203-263-0400
Practice Address - Fax:203-263-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2012-06-22
Deactivation Date:2008-08-01
Deactivation Code:
Reactivation Date:2012-06-22
Provider Licenses
StateLicense IDTaxonomies
CT263CT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
350000183Medicare ID - Type Unspecified