Healthcare Provider Details

I. General information

NPI: 1295022234
Provider Name (Legal Business Name): CONNECTICUT GENERAL LIFE INSURANCE COMPANY (CGLIC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 REYNOLDS WAY
KETTERING OH
45430-1586
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 937-485-9401
  • Fax:
Mailing address:
  • Phone: 877-733-1710
  • Fax: 602-328-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SLICE
Title or Position: VICE PRESIDENT
Credential: RPH
Phone: 602-371-2971