Healthcare Provider Details

I. General information

NPI: 1255462701
Provider Name (Legal Business Name): ADULT FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

850 N MAIN ST EXT BLDG 2 SUITE C2
WALLINGFORD CT
06492
US

IV. Provider business mailing address

850 N MAIN ST EXT BLDG 2 SUITE C2
WALLINGFORD CT
06492
US

V. Phone/Fax

Practice location:
  • Phone: 203-269-9778
  • Fax: 203-949-1544
Mailing address:
  • Phone: 203-269-9778
  • Fax: 203-949-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number038503
License Number StateCT

VIII. Authorized Official

Name: MS. JAMIRA GALARZA
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-269-9778