Provider Demographics
NPI:1588879589
Name:AVON CHIROPRACTIC HEALTH CENTER PC
Entity type:Organization
Organization Name:AVON CHIROPRACTIC HEALTH CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-673-2225
Mailing Address - Street 1:549 W AVON RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2909
Mailing Address - Country:US
Mailing Address - Phone:860-673-2225
Mailing Address - Fax:860-671-7193
Practice Address - Street 1:549 W AVON RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-2909
Practice Address - Country:US
Practice Address - Phone:860-673-2225
Practice Address - Fax:860-671-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT259CT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00410622Medicaid
CT00410622Medicaid