Provider Demographics
NPI:1982604567
Name:MONTOWESE CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:MONTOWESE CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PT
Authorized Official - Phone:203-985-1577
Mailing Address - Street 1:202 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2207
Mailing Address - Country:US
Mailing Address - Phone:203-985-1577
Mailing Address - Fax:203-239-4290
Practice Address - Street 1:202 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2207
Practice Address - Country:US
Practice Address - Phone:203-985-1577
Practice Address - Fax:203-239-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008050328Medicaid
CTD100000046Medicare PIN