MEDICARE: DR. JONATHANS ACUPUNCTURE AND CHIROPRACTIC CTR. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	000925	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992935829	OTHER	CT	SELF NPI

General Provider Information

NPI Number	:	1780918128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. JONATHANS ACUPUNCTURE AND CHIROPRACTIC CTR. LLC

Provider Business Mailing Address
First Line	:	10 COLONIAL RD
Second Line	:
City	:	NEW FAIRFIELD
State	:	CT
Zip	:	06812-5023
Country	:	US
Telephone Number	:	203-546-8736
Fax Number	:	203-775-0057

Provider Business Practice Location Address
First Line	:	10 COLONIAL RD
Second Line	:
City	:	NEW FAIRFIELD
State	:	CT
Zip	:	06812-5023
Country	:	US
Telephone Number	:	203-546-8736
Fax Number	:	203-546-8736

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN DAVID LAVELLE
Credential	:	D.C.
Telephone Number	:	203-546-8736

Provider Enumeration Date	:	10/01/2009
Last Update Date	:	09/09/2013

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