Healthcare Provider Details

I. General information

NPI: 1841522281
Provider Name (Legal Business Name): MOLECULAR NEUROIMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 TEMPLE ST #8A
NEW HAVEN CT
06510-2716
US

IV. Provider business mailing address

60 TEMPLE ST #8A
NEW HAVEN CT
06510-2716
US

V. Phone/Fax

Practice location:
  • Phone: 203-401-4300
  • Fax: 203-401-4304
Mailing address:
  • Phone: 203-401-4300
  • Fax: 203-401-4304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK MARIOTTI
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 203-431-4351