1093997892 NPI number — CONNECTICUT FOOT CARE CENTERS LLC

Table of content: (NPI 1093997892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093997892 NPI number — CONNECTICUT FOOT CARE CENTERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT FOOT CARE CENTERS 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:
1093997892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-563-1200
Provider Business Mailing Address Fax Number:
860-563-2665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
949 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENSINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06037-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-828-3455
Provider Business Practice Location Address Fax Number:
860-828-9557
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAHN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
860-563-1200

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C01816 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C01817 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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