1720130362 NPI number — CONNECTICUT RENAISSANCE, INC.

Table of content: (NPI 1720130362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720130362 NPI number — CONNECTICUT RENAISSANCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT RENAISSANCE, INC.
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:
1720130362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WATERVIEW DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06484-4368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-336-5225
Provider Business Mailing Address Fax Number:
203-336-2851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06604-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-368-9755
Provider Business Practice Location Address Fax Number:
203-368-9760
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATSTON
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
203-336-5225

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  0412 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 0350 , 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: 008002559 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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