Healthcare Provider Details

I. General information

NPI: 1255372108
Provider Name (Legal Business Name): NEW ERA REHABILITATION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 MAIN STREET
BRIDGEPORT CT
06606-2864
US

IV. Provider business mailing address

4675 MAIN STREET
BRIDGEPORT CT
06606-2864
US

V. Phone/Fax

Practice location:
  • Phone: 203-344-0025
  • Fax: 203-374-7515
Mailing address:
  • Phone: 203-344-0025
  • Fax: 203-374-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number042947
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number042947
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number040029
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number0266
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number0266
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0266
License Number StateCT

VIII. Authorized Official

Name: MR. EBENEZER ADEKUNLE KOLADE
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 203-562-2101