1033239249 NPI number — SOUTHERN CT CHRISTIAN NETWORK

Table of content: (NPI 1033239249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033239249 NPI number — SOUTHERN CT CHRISTIAN NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CT CHRISTIAN NETWORK
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:
1033239249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
145 DURHAM RD
Provider Second Line Business Mailing Address:
MAILBOX 7
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06443-2674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-318-0070
Provider Business Mailing Address Fax Number:
206-339-8205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 DURHAM RD
Provider Second Line Business Practice Location Address:
MAILBOX 7
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06443-2674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-318-0070
Provider Business Practice Location Address Fax Number:
206-339-8205
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIKE
Authorized Official First Name:
ULARI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
203-318-0700

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  001460 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 002876 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 004809 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084F0202X , with the licence number: 039301 , 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: 004257269 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004257277 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 307875 . This is a "HEALTHNET-MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004257532 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com