Healthcare Provider Details

I. General information

NPI: 1740297845
Provider Name (Legal Business Name): CONNECTICUT RENAISSANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 MAIN ST
BRIDGEPORT CT
06604-4404
US

IV. Provider business mailing address

350 FAIRFIELD AVE SUITE 701
BRIDGEPORT CT
06604-6014
US

V. Phone/Fax

Practice location:
  • Phone: 203-367-6827
  • Fax: 203-367-7576
Mailing address:
  • Phone: 203-336-5225
  • Fax: 203-336-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0332
License Number StateCT

VIII. Authorized Official

Name: MR. PATRICK MCAULIFFE
Title or Position: CEO
Credential: MBA, LADC
Phone: 203-336-5225