Healthcare Provider Details

I. General information

NPI: 1215958772
Provider Name (Legal Business Name): BACK TO HEALTH OF BRANFORD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WEST MAIN STREET
BRANFORD CT
06405
US

IV. Provider business mailing address

400 W MAIN ST
BRANFORD CT
06405-3416
US

V. Phone/Fax

Practice location:
  • Phone: 203-483-7778
  • Fax: 203-481-0234
Mailing address:
  • Phone: 203-483-7778
  • Fax: 203-481-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number000561
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number148
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002765
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001614
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number037255
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number037255
License Number StateCT
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number037255
License Number StateCT

VIII. Authorized Official

Name: SHARON L BAILEY
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 203-483-7778