Healthcare Provider Details

I. General information

NPI: 1932141298
Provider Name (Legal Business Name): EASTERN CONNECTICUT NEUROLOGY SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 W CENTER ST
MANCHESTER CT
06040-4735
US

IV. Provider business mailing address

PO BOX 3262
VERNON CT
06066-2162
US

V. Phone/Fax

Practice location:
  • Phone: 860-647-9183
  • Fax: 860-647-0582
Mailing address:
  • Phone: 860-896-1422
  • Fax: 860-896-1425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number039584
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number005619
License Number StateCT

VIII. Authorized Official

Name: JESSICA WOODRUFF
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-647-9183