Provider Demographics
NPI:1215958772
Name:BACK TO HEALTH OF BRANFORD, LLC
Entity type:Organization
Organization Name:BACK TO HEALTH OF BRANFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-483-7778
Mailing Address - Street 1:400 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3416
Mailing Address - Country:US
Mailing Address - Phone:203-483-7778
Mailing Address - Fax:203-481-0234
Practice Address - Street 1:400 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405
Practice Address - Country:US
Practice Address - Phone:203-483-7778
Practice Address - Fax:203-481-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT148111N00000X
CT001614111N00000X
CT000561111NI0900X
CT037255207R00000X, 332B00000X, 335E00000X
CT002765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT07D1072612OtherCLIA WAIVER
C02868OtherGROUP
CT008038901Medicaid
CT008038939Medicaid
U18188Medicare UPIN
CT6696760001Medicare NSC
S72173Medicare UPIN
350001195Medicare PIN
CTG93443Medicare UPIN
G93443Medicare UPIN
CT008038939Medicaid