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General NPI Number Information
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NPI Number | 1043348204
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Entity Type | Organization
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Legal Business Name | ST. VINCENT DEPAUL MISSION OF WATERBURY, INC.
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 08/11/2016
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Provider Practice Location Address
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Address Line | 86 MIDLAND RD # 88
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City | WATERBURY
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State | CT
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Zip | 06705-3414
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Country | US
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Telephone | 203-753-3342
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Fax | 203-753-9900
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Provider Business Mailing Address
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Address Line | 173 MARK LN SUITE 6
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City | WATERBURY
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State | CT
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Zip | 06704-2474
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Country | US
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Telephone | 203-757-0567
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Fax | 203-757-0568
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. PAUL IADAROLA
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Credential |
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Telephone | 203-754-0000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | RCL-0029
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License Number State | CT
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