Healthcare Provider Details

I. General information

NPI: 1619020153
Provider Name (Legal Business Name): CTR ADV ORTHO & SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 LITCHFIELD ST SUITE G-01
TORRINGTON CT
06790-6669
US

IV. Provider business mailing address

538 LITCHFIELD ST SUITE G-01
TORRINGTON CT
06790-6669
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-9877
  • Fax: 860-496-0441
Mailing address:
  • Phone: 860-496-9877
  • Fax: 860-496-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number039414
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number493408001
License Number StateCT

VIII. Authorized Official

Name: ANGELA PENNEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 860-496-9877