Healthcare Provider Details

I. General information

NPI: 1811434871
Provider Name (Legal Business Name): CHRISTINA SKUBURIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 BEDFORD STREET
STAMFORD CT
06905
US

IV. Provider business mailing address

2043 BEDFORD STREET
STAMFORD CT
06905
US

V. Phone/Fax

Practice location:
  • Phone: 203-849-0021
  • Fax: 203-849-0021
Mailing address:
  • Phone: 203-849-0021
  • Fax: 203-849-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number003024
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number009912-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number003024
License Number StateCT

VIII. Authorized Official

Name: CHRISTINA SKUBURDIS
Title or Position: OWNER
Credential:
Phone: 203-849-0021