Healthcare Provider Details

I. General information

NPI: 1568614337
Provider Name (Legal Business Name): BYRON ROY EASTERLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 LONG HILL RD
MIDDLETOWN CT
06457-4063
US

IV. Provider business mailing address

PO BOX 118
OLD SAYBROOK CT
06475-0118
US

V. Phone/Fax

Practice location:
  • Phone: 860-227-6630
  • Fax:
Mailing address:
  • Phone: 860-227-6630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number000163
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: