1710166863 NPI number — HARTFORD ORTHOTICS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710166863 NPI number — HARTFORD ORTHOTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARTFORD ORTHOTICS, 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:
1710166863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2842 MAIN ST
Provider Second Line Business Mailing Address:
#212
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-670-5874
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 SHUNPIKE RD
Provider Second Line Business Practice Location Address:
SUITE 41
Provider Business Practice Location Address City Name:
CROMWELL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06416-2497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-635-7653
Provider Business Practice Location Address Fax Number:
860-635-2080
Provider Enumeration Date:
10/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SKORSKI
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-670-5874

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  444102 , 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: 004245511 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: CW0774 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: N292377 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 12DME0838CT01 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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