1205961547 NPI number — CHESHIRE FITNESS ZONE, LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205961547 NPI number — CHESHIRE FITNESS ZONE, LLC

Employer Identification Number (EIN):

Provider Organization Name:

CHESHIRE FITNESS ZONE, LLC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1205961547

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/29/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

382 S MAIN ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHESHIRE

Provider Business Mailing Address State Name:

CT

Provider Business Mailing Address Postal Code:

06410-1379

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

203-250-9663

Provider Business Mailing Address Fax Number:

203-699-9641

Provider First Line Business Practice Location Address:

382 S MAIN ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CHESHIRE

Provider Business Practice Location Address State Name:

CT

Provider Business Practice Location Address Postal Code:

06410-1379

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

203-250-9663

Provider Business Practice Location Address Fax Number:

203-699-9641

Provider Enumeration Date:

02/23/2007

Authorized Official Last Name:

GOLDSTEIN

Authorized Official First Name:

CRAIG

Authorized Official Middle Name:

M.

Authorized Official Title or Position:

OWNER

Authorized Official Telephone Number:

203-250-9663

• Taxonomy code: 174400000X , with the licence number:  005678 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 225XP0200X , with the licence number: 002758 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 235Z00000X , with the licence number: 003550 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2251P0200X , with the licence number: 005678 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0100901 . This is a "AETNA ORTHONET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 100901 . This is a "HEALTHNET ORTHONET - ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 1257980 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 3672389002 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 64-04292 . This is a "UNITED HEALTHCARE ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 754954 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 9168247 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 0800005678CT01 . This is a "BCBS-CRAIG GOLDSTEIN, PT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 080005678CT01 . This is a "BCBS - PROVIDER ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 2370736 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 754954 . This is a "CONNECTICARE - ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 004209674 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
• Identifier: 2V8125 . This is a "HEALTHNET - ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 3672389002 . This is a "CIGNA - PROVIDER ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 50CHESFITCT01 . This is a "BCBS-CHESHIRE FITNESS ZONE, FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 61594157 . This is a "MEDSPAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 0100901 . This is a "BCBS ORTHONET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 660003550CT01 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 9044356 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 12701 . This is a "CIGNA - ORTHONET ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".