Healthcare Provider Details

I. General information

NPI: 1134509615
Provider Name (Legal Business Name): AVON MEDICAL WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 HOPMEADOW ST
SIMSBURY CT
06070-2496
US

IV. Provider business mailing address

540 HOPMEADOW ST
SIMSBURY CT
06070-2496
US

V. Phone/Fax

Practice location:
  • Phone: 860-272-4646
  • Fax: 860-272-4642
Mailing address:
  • Phone: 860-272-4646
  • Fax: 860-272-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number047333
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001816
License Number StateCT

VIII. Authorized Official

Name: DR. OFER SAGIV
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 860-272-4646