1811031610 NPI number — RAYMOND ARTHUR COUTURE #594 LICENSED DISPEN

Table of content: RAYMOND ARTHUR COUTURE #594 LICENSED DISPEN (NPI 1811031610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811031610 NPI number — RAYMOND ARTHUR COUTURE #594 LICENSED DISPEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUTURE
Provider First Name:
RAYMOND
Provider Middle Name:
ARTHUR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
#594 LICENSED DISPEN
Provider Gender Code:
M

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:
1811031610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 FARMINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 16
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06107-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-232-7616
Provider Business Mailing Address Fax Number:
413-572-1308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1007 FARMINGTON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
WEST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06107-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-232-7616
Provider Business Practice Location Address Fax Number:
860-233-4565
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  594 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 156FX1800X , with the licence number: 1270 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004036968 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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