Healthcare Provider Details

I. General information

NPI: 1245295401
Provider Name (Legal Business Name): GREATER WATERBURY IMAGING CENTER LIMITED PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 ROBBINS ST
WATERBURY CT
06708-2613
US

IV. Provider business mailing address

PO BOX 150473 DEPT. 335
HARTFORD CT
06115-0473
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-7674
  • Fax: 203-573-6255
Mailing address:
  • Phone: 949-282-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH S. KELSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 949-282-6000