Healthcare Provider Details

I. General information

NPI: 1366981128
Provider Name (Legal Business Name): SUPERIOR HEALTH CARE OF CT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 WOLCOTT RD
WOLCOTT CT
06716-2639
US

IV. Provider business mailing address

444 WOLCOTT RD
WOLCOTT CT
06716-2639
US

V. Phone/Fax

Practice location:
  • Phone: 203-879-4695
  • Fax: 203-879-4696
Mailing address:
  • Phone: 203-879-4695
  • Fax: 203-879-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number45196
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number006279
License Number StateCT

VIII. Authorized Official

Name: DR. PAUL MICHAEL DIDOMIZIO
Title or Position: MEMBER
Credential: D.C.
Phone: 203-879-4685