Provider Demographics
NPI:1700296894
Name:INDIAN HARBOR CHIROPRACTIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:INDIAN HARBOR CHIROPRACTIC ASSOCIATES LLC
Other - Org Name:INDIAN HARBOR CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAILES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-273-2674
Mailing Address - Street 1:31 RIVER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2152
Mailing Address - Country:US
Mailing Address - Phone:203-983-5426
Mailing Address - Fax:203-622-8228
Practice Address - Street 1:31 RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2152
Practice Address - Country:US
Practice Address - Phone:203-983-5426
Practice Address - Fax:203-622-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001928OtherCT LICENSE
RIDCP00461OtherRI LICENSE