Healthcare Provider Details

I. General information

NPI: 1649929126
Provider Name (Legal Business Name): CONNECTICUT OSTEOPATHIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 DOWD AVE
CANTON CT
06019-2401
US

IV. Provider business mailing address

304 W. MAIN ST SUITE 2, #135
AVON CT
06001
US

V. Phone/Fax

Practice location:
  • Phone: 570-498-4879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA GRONSKI
Title or Position: OWNER
Credential: DO
Phone: 570-498-4879