Provider Demographics
NPI:1306065248
Name:SOUTH WINDSOR NECK AND BACK, LLC
Entity type:Organization
Organization Name:SOUTH WINDSOR NECK AND BACK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:P
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-644-2437
Mailing Address - Street 1:1330 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2713
Mailing Address - Country:US
Mailing Address - Phone:860-644-2437
Mailing Address - Fax:860-644-8590
Practice Address - Street 1:1330 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2713
Practice Address - Country:US
Practice Address - Phone:860-644-2437
Practice Address - Fax:860-644-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011490111N00000X
CT001133111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Not Answered111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1922042563OtherROSANNE GREGORY NPI SOLO
CTC03101OtherMEDICARE GROUP NUMBER
CT1114961703OtherANDREW GREGORY NPI SOLO
CTC03101OtherMEDICARE GROUP NUMBER
CTU55233Medicare UPIN