Healthcare Provider Details

I. General information

NPI: 1215488515
Provider Name (Legal Business Name): DERBY CHIROPRACTIC OFFICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NEW HAVEN AVE
DERBY CT
06418-2197
US

IV. Provider business mailing address

24 LEWIS ST
HARTFORD CT
06103-2501
US

V. Phone/Fax

Practice location:
  • Phone: 203-736-6356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001584
License Number StateCT

VIII. Authorized Official

Name: DR. KARLOS BOGHOSIAN
Title or Position: MEMBER
Credential: D.C.
Phone: 860-278-9141