Healthcare Provider Details

I. General information

NPI: 1992750855
Provider Name (Legal Business Name): CHARTER OAK HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
HARTFORD CT
06106-1541
US

IV. Provider business mailing address

21 GRAND ST
HARTFORD CT
06106-1541
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-7500
  • Fax:
Mailing address:
  • Phone: 860-550-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0312
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0259
License Number StateCT

VIII. Authorized Official

Name: MR. DAVID SEMPLE
Title or Position: CEO
Credential:
Phone: 860-550-7500