Healthcare Provider Details

I. General information

NPI: 1790791481
Provider Name (Legal Business Name): NEW HAVEN MEDICAL SPORTS & OCCUPATIONAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 CHAPEL ST
NEW HAVEN CT
06511-4701
US

IV. Provider business mailing address

1213 CHAPEL ST
NEW HAVEN CT
06511-4701
US

V. Phone/Fax

Practice location:
  • Phone: 203-776-3375
  • Fax: 203-776-3171
Mailing address:
  • Phone: 203-776-3375
  • Fax: 203-776-3171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001097
License Number StateCT

VIII. Authorized Official

Name: STEPHEN PISERCHIA
Title or Position: PRESIDENT
Credential: DC
Phone: 203-776-3375