1629425160 NPI number — GRANT'S NUTRITION AND WELLNESS

Table of content: RACHEL HADDOCK FORRESTER PT (NPI 1275942120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629425160 NPI number — GRANT'S NUTRITION AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANT'S NUTRITION AND WELLNESS
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:
1629425160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37 WEBSTER SQUARE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06037-2326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-357-2282
Provider Business Mailing Address Fax Number:
860-357-2555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 WEBSTER SQUARE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06037-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-357-2282
Provider Business Practice Location Address Fax Number:
860-357-2555
Provider Enumeration Date:
05/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GRANT
Authorized Official First Name:
JANE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-357-2282

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1199 , 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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