1790725588 NPI number — CHARTWELL SOUTHERN NEW ENGLAND, LLC

Table of content: (NPI 1790725588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790725588 NPI number — CHARTWELL SOUTHERN NEW ENGLAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARTWELL SOUTHERN NEW ENGLAND, LLC
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:
OPTION CARE
Provider Other Organization Name Type Code:
3
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:
1790725588
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3026 PAYSPHERE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-879-6137
Provider Business Mailing Address Fax Number:
847-913-9024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 CLARK DR
Provider Second Line Business Practice Location Address:
UNITE 1-A
Provider Business Practice Location Address City Name:
EAST BERLIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06023-1157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-755-1511
Provider Business Practice Location Address Fax Number:
860-828-0029
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BONACCORSI
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
847-229-7794

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1385 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 1385 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1385 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 1385 , 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: 004129822 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004131132 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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