Healthcare Provider Details

I. General information

NPI: 1972273282
Provider Name (Legal Business Name): OPERATION LIFESTYLE REDESIGN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 WOOSTER HEIGHTS SUITE #125
DANBURY CT
06810
US

IV. Provider business mailing address

33 DIXWELL AVE STE 278
NEW HAVEN CT
06511-3403
US

V. Phone/Fax

Practice location:
  • Phone: 203-957-3938
  • Fax: 866-266-4842
Mailing address:
  • Phone: 203-957-3938
  • Fax: 866-266-4842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON DAVAR PERVIS SR.
Title or Position: VICE PRESIDENT OF CLINICAL OPERATIO
Credential: APRN
Phone: 203-957-3938