Healthcare Provider Details

I. General information

NPI: 1790725588
Provider Name (Legal Business Name): CHARTWELL SOUTHERN NEW ENGLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 CLARK DR UNITE 1-A
EAST BERLIN CT
06023-1157
US

IV. Provider business mailing address

3026 PAYSPHERE CIR
CHICAGO IL
60674-0030
US

V. Phone/Fax

Practice location:
  • Phone: 800-755-1511
  • Fax: 860-828-0029
Mailing address:
  • Phone: 800-879-6137
  • Fax: 847-913-9024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number1385
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1385
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1385
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number1385
License Number StateCT

VIII. Authorized Official

Name: JOSEPH BONACCORSI
Title or Position: MANAGING MEMBER
Credential: JD
Phone: 847-229-7794