1750379293 NPI number — ROY B PETTENGILL AMB ASSOC

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 1750379293 NPI number — ROY B PETTENGILL AMB ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROY B PETTENGILL AMB ASSOC
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:
1750379293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLBOROUGH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06447-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-402-5899
Provider Business Mailing Address Fax Number:
860-721-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 HEBRON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLBOROUGH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06447-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-295-6219
Provider Business Practice Location Address Fax Number:
860-295-0604
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TARKA
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-402-5899

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  C079B1 , 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)

  • Identifier: 004224565 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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