Provider Demographics
NPI:1932456068
Name:HEADZONE LLC
Entity Type:Organization
Organization Name:HEADZONE LLC
Other - Org Name:HEADZONE CONCUSSION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASQUILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-527-3181
Mailing Address - Street 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-527-3181
Mailing Address - Fax:
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 325
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-527-3181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCLPOL0098261QH0100X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service