1982151635 NPI number — STAYWELL HEALTH CARE INC

Table of content: (NPI 1982151635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982151635 NPI number — STAYWELL HEALTH CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAYWELL HEALTH CARE 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:
1982151635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAUGATUCK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06770-4112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-805-4929
Provider Business Mailing Address Fax Number:
844-668-4620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAUGATUCK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06770-4112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-805-4929
Provider Business Practice Location Address Fax Number:
844-668-4620
Provider Enumeration Date:
09/09/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
203-756-8021

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0787 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 0787 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004235968 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004235976 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1154342335 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004235984 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".