Healthcare Provider Details

I. General information

NPI: 1053785832
Provider Name (Legal Business Name): CHARTER OAK HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 11/17/2015
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: 860-550-7529
Mailing address:
  • Phone: 860-550-7500
  • Fax: 860-550-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0312
License Number StateCT

VIII. Authorized Official

Name: SHANNON P. DONAHUE
Title or Position: INTERIM CFO
Credential:
Phone: 860-550-7524