Provider Demographics
NPI:1043486947
Name:ADVANCED BACK CENTER
Entity type:Organization
Organization Name:ADVANCED BACK CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:RAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-621-2225
Mailing Address - Street 1:200 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1901
Mailing Address - Country:US
Mailing Address - Phone:860-621-2225
Mailing Address - Fax:860-621-2868
Practice Address - Street 1:200 QUEEN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1901
Practice Address - Country:US
Practice Address - Phone:860-621-2225
Practice Address - Fax:860-621-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000938111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01587Medicare PIN