1881814960 NPI number — LAD FAMILY FIRST

Table of content: (NPI 1881814960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881814960 NPI number — LAD FAMILY FIRST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAD FAMILY FIRST
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:
6
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:
1881814960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
994 NORTH COLONY RD
Provider Second Line Business Mailing Address:
SUITE #343
Provider Business Mailing Address City Name:
WALLINGFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-5902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-269-5552
Provider Business Mailing Address Fax Number:
203-265-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 NORTH COLONY RD
Provider Second Line Business Practice Location Address:
SUITE 343
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-269-5552
Provider Business Practice Location Address Fax Number:
203-265-3512
Provider Enumeration Date:
04/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
203-269-5552

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  1806090000 , 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: 004LADF492 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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