1063400414 NPI number — WILLINGTON FIRE DEPT #1

Table of content: (NPI 1063400414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063400414 NPI number — WILLINGTON FIRE DEPT #1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLINGTON FIRE DEPT #1
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:
WILLINGTON FIRE DEPT #1
Provider Other Organization Name Type Code:
5
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:
1063400414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
W SUFFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-668-3885
Provider Business Mailing Address Fax Number:
860-668-3885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06279-1310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-429-0288
Provider Business Practice Location Address Fax Number:
860-487-4545
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GANTICK
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
AMBULANCE CHIEF
Authorized Official Telephone Number:
860-429-0288

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  C160B1 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X , with the licence number: C160B1 , 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: 590009415 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 710C160B1CT01 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004119857 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5300009415 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 756028 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".




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