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General NPI Number Information
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NPI Number | 1245788512
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Entity Type | Organization
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Legal Business Name | NEW HAVEN CHIROPRACTIC & SPORTS REHABILITATION LLC
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Dates
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Enumeration Date | 09/15/2016
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Last Update Date | 09/15/2016
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Provider Practice Location Address
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Address Line | 1213 CHAPEL ST
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City | NEW HAVEN
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State | CT
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Zip | 06511-4701
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Country | US
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Telephone | 203-376-7726
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Fax | 347-823-1718
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Provider Business Mailing Address
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Address Line | 1213 CHAPEL ST
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City | NEW HAVEN
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State | CT
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Zip | 06511-4701
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Country | US
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Telephone | 203-376-7726
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Fax | 347-823-1718
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Authorized Official
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Title or Position | OWNER
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Name | GREGORY HOM
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Credential | D.C.
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Telephone | 203-376-7726
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2028
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License Number State | CT
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