Healthcare Provider Details

I. General information

NPI: 1760408835
Provider Name (Legal Business Name): SOUTH WINDSOR AMBULATORY CARE CTR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 TAMARACK AVENUE SUITE 105
SOUTH WINDSOR CT
06074-5539
US

IV. Provider business mailing address

PO BOX 510
SOUTH WINDSOR CT
06074-0510
US

V. Phone/Fax

Practice location:
  • Phone: 860-644-3491
  • Fax: 860-644-5744
Mailing address:
  • Phone: 860-644-3491
  • Fax: 860-644-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number24303
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number024303
License Number StateCT

VIII. Authorized Official

Name: MRS. BARBARA M PETRONE
Title or Position: OFFICE MANAGER
Credential: RTR
Phone: 860-644-3491