Healthcare Provider Details

I. General information

NPI: 1467860635
Provider Name (Legal Business Name): JMSEJB1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3034 SUMMER ST
STAMFORD CT
06905-4311
US

IV. Provider business mailing address

24 LEWIS ST
HARTFORD CT
06103-2501
US

V. Phone/Fax

Practice location:
  • Phone: 860-278-9141
  • Fax: 860-525-4013
Mailing address:
  • Phone: 860-278-9141
  • Fax: 860-525-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001584
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number001313
License Number StateCT

VIII. Authorized Official

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