Healthcare Provider Details

I. General information

NPI: 1104946896
Provider Name (Legal Business Name): PLYMOUTH BD OF ED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MAIN ST
TERRYVILLE CT
06786-5104
US

IV. Provider business mailing address

77 MAIN ST
TERRYVILLE CT
06786-5104
US

V. Phone/Fax

Practice location:
  • Phone: 860-314-2768
  • Fax: 860-314-2766
Mailing address:
  • Phone: 860-314-2768
  • Fax: 860-314-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateCT

VIII. Authorized Official

Name: MR. GERARD PERUSSE PERUSSE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 860-314-2768