1417143504 NPI number — HOUSATONIC VALLEY HEALTH DISTRICT

Table of content: (NPI 1417143504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417143504 NPI number — HOUSATONIC VALLEY HEALTH DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOUSATONIC VALLEY HEALTH DISTRICT
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:
1417143504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 MAIN STREET NORTH
Provider Second Line Business Mailing Address:
SUITE #205
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-264-9616
Provider Business Mailing Address Fax Number:
203-262-1960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 MAIN STREET NORTH
Provider Second Line Business Practice Location Address:
SUITE #205
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-264-9616
Provider Business Practice Location Address Fax Number:
203-262-1960
Provider Enumeration Date:
09/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BETHGE
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF HEALTH
Authorized Official Telephone Number:
203-264-9616

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  0939 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2V5218 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 899051 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 68 VNA0071CT01 . This is a "ANTHEM B.C. & B.S." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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