Healthcare Provider Details

I. General information

NPI: 1417694860
Provider Name (Legal Business Name): MAURICIO FORONDA SUB IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE BLDG 499
GROTON CT
06349-2324
US

IV. Provider business mailing address

1 WAHOO AVE BLDG 449
GROTON CT
06349-2324
US

V. Phone/Fax

Practice location:
  • Phone: 862-812-9757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: