Healthcare Provider Details

I. General information

NPI: 1447642889
Provider Name (Legal Business Name): ROBERT GENDREAU JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 OAKWOOD AVE
WEST HARTFORD CT
06119-2141
US

IV. Provider business mailing address

173 OAKWOOD AVE
WEST HARTFORD CT
06119-2141
US

V. Phone/Fax

Practice location:
  • Phone: 415-515-9734
  • Fax:
Mailing address:
  • Phone: 415-515-9734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: