Healthcare Provider Details

I. General information

NPI: 1114129277
Provider Name (Legal Business Name): CAROLE DEMAREST RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST JOSLIN DIABETES CENTER
NEW BRITAIN CT
06052-2016
US

IV. Provider business mailing address

100 GRAND ST MEDICAL STAFF OFFICE
NEW BRITAIN CT
06052-2016
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5672
  • Fax: 860-224-5565
Mailing address:
  • Phone: 860-224-5305
  • Fax: 860-224-5565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number000801
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: