Healthcare Provider Details

I. General information

NPI: 1366687790
Provider Name (Legal Business Name): GERICARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 WOLCOTT RD
WOLCOTT CT
06716-2626
US

IV. Provider business mailing address

464 WOLCOTT RD
WOLCOTT CT
06716-2626
US

V. Phone/Fax

Practice location:
  • Phone: 203-633-4560
  • Fax:
Mailing address:
  • Phone: 203-633-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN J BRENES
Title or Position: CEO
Credential:
Phone: 203-910-7533