Healthcare Provider Details

I. General information

NPI: 1780810820
Provider Name (Legal Business Name): CDMI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MASONS ISLAND RD SUITE 14C - BOX 15
MYSTIC CT
06355-2958
US

IV. Provider business mailing address

14 MASONS ISLAND RD SUITE 14C - BOX 15
MYSTIC CT
06355-2958
US

V. Phone/Fax

Practice location:
  • Phone: 860-415-4534
  • Fax: 888-476-0283
Mailing address:
  • Phone: 860-415-4534
  • Fax: 888-476-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberAPPLICATION IN PROCE
License Number StateCT

VIII. Authorized Official

Name: MR. REED CYPRIANO
Title or Position: OPERATIONS DIRECTOR
Credential: CERT. COMPR. THEART.
Phone: 860-415-4532