=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245577998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN PATRICK CONNER D.C., CNS, CDN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2013
-----------------------------------------------------
Last Update Date | 12/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 366 FEDERAL RD
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06804-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-775-1819
-----------------------------------------------------
Fax | 203-775-2028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 366 FEDERAL RD
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06804-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-775-1819
-----------------------------------------------------
Fax | 203-775-2028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 1485
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1931
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 012297
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------