1003960022 NPI number — SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE INC

Table of content: (NPI 1003960022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003960022 NPI number — SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SCADD INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003960022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 CAMP MOOWEEN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-886-2495
Provider Business Mailing Address Fax Number:
860-887-0007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 CAMP MOOWEEN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-889-1717
Provider Business Practice Location Address Fax Number:
860-886-2361
Provider Enumeration Date:
01/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
860-886-2495

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  0439 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 0343 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X , with the licence number: SA0020 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , with the licence number: SA-0018 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004173671 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004042073 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004144606 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 175904 . This is a "MAGELLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 149925 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".