1649321696 NPI number — CONNECTICUT RENAISSANCE, INC

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 1649321696 NPI number — CONNECTICUT RENAISSANCE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT RENAISSANCE, INC
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:
1649321696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WATERVIEW DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06484-4368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-336-5225
Provider Business Mailing Address Fax Number:
203-336-2851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 WOLCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-1727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-753-2341
Provider Business Practice Location Address Fax Number:
203-755-6902
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PENDOLA
Authorized Official First Name:
JOY
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
203-336-5225

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  SA-0056 , 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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