Provider Demographics
NPI:1316488927
Name:NEW CANAAN CHIROPRACTIC LLC
Entity type:Organization
Organization Name:NEW CANAAN CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, DULY AUTHORIZED
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-966-9777
Mailing Address - Street 1:111 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5419
Mailing Address - Country:US
Mailing Address - Phone:203-966-9777
Mailing Address - Fax:203-966-0778
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5419
Practice Address - Country:US
Practice Address - Phone:203-966-9777
Practice Address - Fax:203-966-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT001042111N00000X, 111NN0400X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004127123Medicaid
CTP420681OtherOXFORD
CT004127123Medicaid
CTU41692Medicare UPIN