1114165511 NPI number — ECHN JOHNSON EVERGREEN CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114165511 NPI number — ECHN JOHNSON EVERGREEN CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ECHN JOHNSON EVERGREEN CORPORATION
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:
1114165511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06040-4144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-646-1222
Provider Business Mailing Address Fax Number:
860-647-6801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 CHESTNUT HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD SPRINGS
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06076-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-684-6341
Provider Business Practice Location Address Fax Number:
860-684-8717
Provider Enumeration Date:
01/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
860-533-2925

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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