Healthcare Provider Details

I. General information

NPI: 1154308229
Provider Name (Legal Business Name): EAST GRANBY FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CHURCH RD
EAST GRANBY CT
06026-0518
US

IV. Provider business mailing address

13 CHURCH RD PO BOX 518
EAST GRANBY CT
06026-0518
US

V. Phone/Fax

Practice location:
  • Phone: 860-653-4526
  • Fax: 860-653-5209
Mailing address:
  • Phone: 860-653-4526
  • Fax: 860-653-5209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN R DIETRICH
Title or Position: PARTNER MD
Credential: MD
Phone: 860-653-4526