Healthcare Provider Details

I. General information

NPI: 1497307573
Provider Name (Legal Business Name): INTERCOMMUNITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 SULLIVAN AVE FL 1
SOUTH WINDSOR CT
06074-2093
US

IV. Provider business mailing address

111 FOUNDERS PLZ STE 1802
EAST HARTFORD CT
06108-8301
US

V. Phone/Fax

Practice location:
  • Phone: 860-569-5900
  • Fax: 860-310-2127
Mailing address:
  • Phone: 860-569-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY L BEAUREGARD
Title or Position: CEO
Credential:
Phone: 860-569-5900