1437437431 NPI number — COURAGE TO GROW, LLC

Table of content: (NPI 1437437431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437437431 NPI number — COURAGE TO GROW, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COURAGE TO GROW, 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:
1437437431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
162 B EAST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-664-3592
Provider Business Mailing Address Fax Number:
860-664-3906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 B EAST MAIN STREET
Provider Second Line Business Practice Location Address:
COURAGE TO GROW, LLC
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-664-3592
Provider Business Practice Location Address Fax Number:
860-664-3906
Provider Enumeration Date:
07/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ISAAC
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-664-3592

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  005911 , 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: 008002029 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9560177 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P4074057 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0062-0087436 . This is a "UNITED HEALTHCARE SERVICES, INC." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 469787 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 140005911CT01 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9560177 . This is a "AETNA PROVIDER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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