1710415658 NPI number — JENNIFER BADEAU, LLC

Table of content: GILBERT LOSBANES VERAR CRNA (NPI 1386885978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710415658 NPI number — JENNIFER BADEAU, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNIFER BADEAU, 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:
1710415658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 CLYDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06042-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 SILAS DEANE HWY UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKY HILL
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06067-2330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-810-5915
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BADEAU
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-810-5915

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  001364 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008016362 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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