Provider Demographics
NPI:1215117486
Name:OEMCKE CHIROPRACTIC/ACUPUNCTURE CENTER,LLC
Entity type:Organization
Organization Name:OEMCKE CHIROPRACTIC/ACUPUNCTURE CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:OEMCKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-267-4464
Mailing Address - Street 1:10 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2260
Mailing Address - Country:US
Mailing Address - Phone:203-267-4464
Mailing Address - Fax:203-267-4468
Practice Address - Street 1:10 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2260
Practice Address - Country:US
Practice Address - Phone:203-267-4464
Practice Address - Fax:203-267-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT992111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCO2113Medicare PIN