Healthcare Provider Details

I. General information

NPI: 1003470170
Provider Name (Legal Business Name): ST. VINCENTS URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3272 MAIN ST
STRATFORD CT
06614-4819
US

IV. Provider business mailing address

2720 MAIN ST
BRIDGEPORT CT
06606-5363
US

V. Phone/Fax

Practice location:
  • Phone: 203-696-3500
  • Fax:
Mailing address:
  • Phone: 475-210-5346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LLATOYA GAYLE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 475-210-5346