Healthcare Provider Details

I. General information

NPI: 1871744243
Provider Name (Legal Business Name): WAIRE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WEST RD
ELLINGTON CT
06029-5700
US

IV. Provider business mailing address

105 WEST RD
ELLINGTON CT
06029-4247
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-5402
  • Fax: 860-871-5413
Mailing address:
  • Phone: 860-871-5402
  • Fax: 860-871-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number043112
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number043112
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number043112
License Number StateCT

VIII. Authorized Official

Name: DR. ERUM SHAHAB
Title or Position: OWNER
Credential: MD
Phone: 860-871-5402