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General NPI Number Information
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NPI Number | 1093254880
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Entity Type | Organization
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Legal Business Name | BACK TO MOTION SPORTS REHAB AND FITNESS
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 435 WILLARD AVE SUITE B
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City | NEWINGTON
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State | CT
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Zip | 06111-2318
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Country | US
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Telephone | 860-665-0826
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Fax | 860-665-0826
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Provider Business Mailing Address
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Address Line | 435 WILLARD AVE SUITE B
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City | NEWINGTON
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State | CT
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Zip | 06111-2318
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Country | US
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Telephone | 860-665-0826
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Fax | 860-665-0826
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. BRADLEY ADAM VISCONTI
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Credential | D.C
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Telephone | 860-248-9989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 2055
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License Number State | CT
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