1497115380 NPI number — AVON FAMILY HEALTH, LLC

Table of content: (NPI 1497115380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497115380 NPI number — AVON FAMILY HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVON FAMILY HEALTH, 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:
1497115380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/19/2017
NPI Reactivation Date:
07/20/2017

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 W AVON RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06001-3678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-675-6595
Provider Business Mailing Address Fax Number:
860-673-6721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 W AVON RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06001-3678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-675-6595
Provider Business Practice Location Address Fax Number:
860-673-6721
Provider Enumeration Date:
03/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LEAHY
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
860-675-6595

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , 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: 004238003 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11243173 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1669496113 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11000341 . This is a "GROUP MEDICAID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D400060973 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7327000 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 637238 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P4395587 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1100341 . This is a "GROUP MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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