1235364571 NPI number — PROXTALKER.COM,LLC

Table of content: (NPI 1235364571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235364571 NPI number — PROXTALKER.COM,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROXTALKER.COM,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:
1235364571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 HUNTINGDON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-1413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-721-6074
Provider Business Mailing Address Fax Number:
203-721-6070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 HUNTINGDON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-1413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-721-6074
Provider Business Practice Location Address Fax Number:
203-721-6070
Provider Enumeration Date:
05/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DOBBS
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-721-6074

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  45099520-001 , 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: 008042594 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102818350 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6710460 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 122970024 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235364571 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0081680 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03559886 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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