1881910875 NPI number — AVADA OF CONNECTICUT, INC.

Table of content: (NPI 1881910875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881910875 NPI number — AVADA OF CONNECTICUT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVADA OF CONNECTICUT, 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:
Provider Other Organization Name Type Code:
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:
1881910875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
459 RIVERDALE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01089-4605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-733-3196
Provider Business Mailing Address Fax Number:
413-736-1037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2A PASCO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06088-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-292-6801
Provider Business Practice Location Address Fax Number:
860-292-6802
Provider Enumeration Date:
04/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BARTOLUCCI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
413-733-3196

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  63-0000051 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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