1396724811 NPI number — PROVIDERCARE PLUS PC

Table of content: (NPI 1396724811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396724811 NPI number — PROVIDERCARE PLUS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDERCARE PLUS PC
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:
1396724811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 DEMING ST
Provider Second Line Business Mailing Address:
PROVIDERCARE PLUS
Provider Business Mailing Address City Name:
SOUTH WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06074-3740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-644-4472
Provider Business Mailing Address Fax Number:
860-644-3001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 DEMING ST
Provider Second Line Business Practice Location Address:
PROVIDERCARE PLUS
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-3740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-644-4472
Provider Business Practice Location Address Fax Number:
860-644-3001
Provider Enumeration Date:
01/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARDAMONE
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
DIRECTOR & CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
860-644-4472

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004398055 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com