1043477045 NPI number — VASECTOMY CENTER OF CONNECTICUT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043477045 NPI number — VASECTOMY CENTER OF CONNECTICUT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VASECTOMY CENTER OF CONNECTICUT, 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:
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:
1043477045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06025-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-430-5773
Provider Business Mailing Address Fax Number:
860-430-5773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 TAMARACK RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-5539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-430-5773
Provider Business Practice Location Address Fax Number:
860-430-5773
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MATSON
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-430-5773

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  040285 , 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: 7190376 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 8711289 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001402859 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040285 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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