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General NPI Number Information
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NPI Number | 1598258519
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Entity Type | Organization
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Legal Business Name | CONNECTICUT SPORTS CLINIC LLC
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Dates
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Enumeration Date | 06/13/2018
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Last Update Date | 03/21/2025
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Provider Practice Location Address
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Address Line | 129 CHURCH ST FL 1
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City | NEW HAVEN
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State | CT
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Zip | 06510-2026
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Country | US
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Telephone | 203-200-0099
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Fax |
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Provider Business Mailing Address
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Address Line | 57 ORANGE ST
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City | NEW HAVEN
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State | CT
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Zip | 06510-3150
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Country | US
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Telephone | 203-589-0226
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Fax |
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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 | DC
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Telephone | 203-589-0226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2028
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License Number State | CT
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