Healthcare Provider Details

I. General information

NPI: 1144591595
Provider Name (Legal Business Name): THE PEDIATRIC CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 FARMINGTON AVE
BRISTOL CT
06010-3920
US

IV. Provider business mailing address

780 FARMINGTON AVE
BRISTOL CT
06010-3920
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-4501
  • Fax: 860-589-4502
Mailing address:
  • Phone: 860-589-4501
  • Fax: 860-589-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number038949
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number002742
License Number StateCT

VIII. Authorized Official

Name: DR. SUSAN ADEYINKA
Title or Position: OWNER
Credential: M.D.
Phone: 860-589-4501