Provider Demographics
NPI:1699063065
Name:BRIAN P BATHERSON
Entity type:Organization
Organization Name:BRIAN P BATHERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BATHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-429-8280
Mailing Address - Street 1:2 HANKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2213
Mailing Address - Country:US
Mailing Address - Phone:860-429-8280
Mailing Address - Fax:860-429-1812
Practice Address - Street 1:2 HANKS HILL RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2213
Practice Address - Country:US
Practice Address - Phone:860-429-8280
Practice Address - Fax:860-429-1812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000550111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6582880001Medicare NSC
CT1699063065Medicare NSC