=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740636760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORWALK SPORTS & SPINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2016
-----------------------------------------------------
Last Update Date | 05/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 488 MAIN AVE 2ND FLOOR
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-842-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 488 MAIN AVE 2ND FLOOR
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | JASON QUEIROS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 203-842-8052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1810
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------