Healthcare Provider Details

I. General information

NPI: 1922296110
Provider Name (Legal Business Name): EDWARD C. CORSELLO D.C. L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 MAIN ST
STRATFORD CT
06614-4861
US

IV. Provider business mailing address

3333 MAIN ST
STRATFORD CT
06614-4861
US

V. Phone/Fax

Practice location:
  • Phone: 203-381-1800
  • Fax: 203-381-1801
Mailing address:
  • Phone: 203-381-1800
  • Fax: 203-381-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number001562
License Number StateCT

VIII. Authorized Official

Name: DR. EDWARD CORSELLO
Title or Position: OWNER/DOCTOR
Credential: D.C.
Phone: 203-381-1800