1386821882 NPI number — STATE OF CONNECTICUT HEALTH CENTER

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 1386821882 NPI number — STATE OF CONNECTICUT HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF CONNECTICUT HEALTH CENTER
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:
APRN, ORTHOPAEDICS
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:
1386821882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 FARMINGTON AVE
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT - DOWLING SOUTH
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06030-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-679-7503
Provider Business Mailing Address Fax Number:
860-679-1610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
APRN, ORTHOPAEDICS
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-679-7503
Provider Business Practice Location Address Fax Number:
860-679-1610
Provider Enumeration Date:
01/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LAFRENIERE
Authorized Official First Name:
DENIS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
860-679-7503

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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