Healthcare Provider Details

I. General information

NPI: 1982151635
Provider Name (Legal Business Name): STAYWELL HEALTH CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CHURCH ST
NAUGATUCK CT
06770-4112
US

IV. Provider business mailing address

30 CHURCH ST
NAUGATUCK CT
06770-4112
US

V. Phone/Fax

Practice location:
  • Phone: 203-805-4929
  • Fax: 844-668-4620
Mailing address:
  • Phone: 203-805-4929
  • Fax: 844-668-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0787
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0787
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCT

VIII. Authorized Official

Name: DONALD THOMPSON
Title or Position: CEO/PRESIDENT
Credential:
Phone: 203-756-8021