1043326010 NPI number — YALE COMFORT SHOE CENTER LLC

Table of content: (NPI 1043326010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043326010 NPI number — YALE COMFORT SHOE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YALE COMFORT SHOE CENTER 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:
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:
1043326010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
627 CHAPEL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06511-6992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-777-2396
Provider Business Mailing Address Fax Number:
203-777-4617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 BOSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06614-5246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-372-7112
Provider Business Practice Location Address Fax Number:
203-338-8437
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAUFMAN
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
203-777-2396

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12DME0905CT01 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OV6079 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004096295 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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