Healthcare Provider Details

I. General information

NPI: 1891026878
Provider Name (Legal Business Name): OSTEOPATHIC WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 DANBURY RD SUITE 6
RIDGEFIELD CT
06877-3227
US

IV. Provider business mailing address

158 DANBURY RD SUITE 6
RIDGEFIELD CT
06877-3227
US

V. Phone/Fax

Practice location:
  • Phone: 203-438-9915
  • Fax: 203-431-4414
Mailing address:
  • Phone: 203-438-9915
  • Fax: 203-431-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number000523
License Number StateCT

VIII. Authorized Official

Name: DR. DAVID L JOHNSTON
Title or Position: OWNER
Credential: DO
Phone: 203-438-9915