=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306022496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROHEALTH CHIROPRACTIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 TOLLAND TURNPIKE SUITE 102
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-432-7432
-----------------------------------------------------
Fax | 860-432-7432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 TOLLAND TURNPIKE SUITE 102
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-432-7432
-----------------------------------------------------
Fax | 860-432-9049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER CHIROPRACTOR
-----------------------------------------------------
Name | DR. JASON ALLEN SOUSA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 860-432-7432
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 001722
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 001726
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------