=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154337707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED HEALTH SPORTS & OCCUPATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 09/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 970 SUMMER ST
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-348-0123
-----------------------------------------------------
Fax | 203-348-5678
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 970 SUMMER ST
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-348-0123
-----------------------------------------------------
Fax | 203-348-5678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. REUBEN MALKIEL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 203-348-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 001237
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------