Healthcare Provider Details

I. General information

NPI: 1649427998
Provider Name (Legal Business Name): STAYWELL HEALTH CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BENEDICT ST
WATERBURY CT
06706-1007
US

IV. Provider business mailing address

80 PHOENIX AVE STE 201
WATERBURY CT
06702-1418
US

V. Phone/Fax

Practice location:
  • Phone: 203-756-8021
  • Fax: 203-596-9038
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-596-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD THOMPSON
Title or Position: PRESIDENT
Credential:
Phone: 203-756-8021