1760790612 NPI number — LESLIE N BROWN P.A.

Table of content: LESLIE N BROWN P.A. (NPI 1760790612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760790612 NPI number — LESLIE N BROWN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
LESLIE
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRIFFINS
Provider Other First Name:
LESLIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760790612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79 WAWECUS ST
Provider Second Line Business Mailing Address:
STE. 101
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06360-2160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-886-2655
Provider Business Mailing Address Fax Number:
860-886-2655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 WAWECUS ST
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06360-2160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-886-2655
Provider Business Practice Location Address Fax Number:
860-886-2655
Provider Enumeration Date:
09/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  002505 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 002505 , 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: 008030891 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9705626 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com