Healthcare Provider Details

I. General information

NPI: 1073943668
Provider Name (Legal Business Name): PEDIATRIC WALK IN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 B HAZARD AVENUE
ENFIELD CT
06082-5412
US

IV. Provider business mailing address

141 B HAZARD AVENUE
ENFIELD CT
06082-5412
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-7603
  • Fax: 860-749-7604
Mailing address:
  • Phone: 860-749-7603
  • Fax: 860-749-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number032413
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number032413
License Number StateCT

VIII. Authorized Official

Name: MR. HEMANT K PANCHAL
Title or Position: OWNER
Credential: M.D.
Phone: 860-749-7603