Healthcare Provider Details

I. General information

NPI: 1316488927
Provider Name (Legal Business Name): NEW CANAAN CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST
NEW CANAAN CT
06840-5419
US

IV. Provider business mailing address

111 ELM ST
NEW CANAAN CT
06840-5419
US

V. Phone/Fax

Practice location:
  • Phone: 203-966-9777
  • Fax: 203-966-0778
Mailing address:
  • Phone: 203-966-9777
  • Fax: 203-966-0778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCT001042
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License NumberCT001042
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCT001042
License Number StateCT

VIII. Authorized Official

Name: DR. BRADLEY A WILLIAMS
Title or Position: MEMBER, DULY AUTHORIZED
Credential: D.C.
Phone: 203-966-9777