Healthcare Provider Details

I. General information

NPI: 1699212704
Provider Name (Legal Business Name): GCNT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GRANDVIEW AVE STE 105
WATERBURY CT
06708-2517
US

IV. Provider business mailing address

171 GRANDVIEW AVE STE 105
WATERBURY CT
06708-2517
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-2214
  • Fax: 203-596-1133
Mailing address:
  • Phone: 203-755-2214
  • Fax: 203-596-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number028148
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number028148
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number028148
License Number StateCT

VIII. Authorized Official

Name: GIAC-CHAN NGUYEN-TAN
Title or Position: SOLE MBR
Credential: MD
Phone: 203-848-7994