Healthcare Provider Details

I. General information

NPI: 1912156845
Provider Name (Legal Business Name): CONNECTICUT KIDNEY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 INDIAN RIVER RD SUITE A5
ORANGE CT
06477-3649
US

IV. Provider business mailing address

240 INDIAN RIVER RD SUITE A5
ORANGE CT
06477-3649
US

V. Phone/Fax

Practice location:
  • Phone: 203-799-1252
  • Fax: 203-799-1252
Mailing address:
  • Phone: 203-799-1252
  • Fax: 203-799-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: MAUREEN ONOFRIO
Title or Position: BILLING MANAGER
Credential:
Phone: 203-799-1252