Provider Demographics
NPI:1487436929
Name:OSTEOPATHIC CENTER OF GLASTONBURY PLLC
Entity type:Organization
Organization Name:OSTEOPATHIC CENTER OF GLASTONBURY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WADDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-729-4862
Mailing Address - Street 1:78 EASTERN BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4325
Mailing Address - Country:US
Mailing Address - Phone:860-729-4682
Mailing Address - Fax:
Practice Address - Street 1:78 EASTERN BLVD STE 6
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4325
Practice Address - Country:US
Practice Address - Phone:860-729-4682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty