Healthcare Provider Details

I. General information

NPI: 1861867608
Provider Name (Legal Business Name): SENIOR DEPOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FEDERAL RD SUITE 2
BROOKFIELD CT
06804-2556
US

IV. Provider business mailing address

195 FEDERAL RD SUITE 2
BROOKFIELD CT
06804-2556
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-1095
  • Fax: 203-775-1098
Mailing address:
  • Phone: 203-775-1095
  • Fax: 203-775-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1055498
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number1055498
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number1055498
License Number StateCT

VIII. Authorized Official

Name: MR. MARTIN ALAN LYNCH
Title or Position: OWNER
Credential:
Phone: 203-241-5113