1205042793 NPI number — EASTERN REHABILITATION NETWORK HEADACHE CLINIC

Table of content: (NPI 1205042793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205042793 NPI number — EASTERN REHABILITATION NETWORK HEADACHE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN REHABILITATION NETWORK HEADACHE CLINIC
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:
1205042793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
181 PATRICIA GENOVA DRIVE
Provider Second Line Business Mailing Address:
EASTERN REHABILITATION NETWORK (5TH FLOOR)
Provider Business Mailing Address City Name:
NEWINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-667-5480
Provider Business Mailing Address Fax Number:
860-667-8416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
144 MAIN STREET
Provider Second Line Business Practice Location Address:
HEADACHE CLINIC
Provider Business Practice Location Address City Name:
EAST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-657-4723
Provider Business Practice Location Address Fax Number:
860-652-4340
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARISI
Authorized Official First Name:
RITA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
860-667-5480

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225X00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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