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General NPI Number Information
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NPI Number | 1114747904
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Entity Type | Organization
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Legal Business Name | MAKE OVER 2710 INC
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Dates
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Enumeration Date | 10/15/2024
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Last Update Date | 10/25/2024
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Provider Practice Location Address
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Address Line | 60 WESTWOOD AVE # 315
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City | WATERBURY
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State | CT
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Zip | 06708-2460
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Country | US
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Telephone | 203-519-0503
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Fax |
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Provider Business Mailing Address
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Address Line | 80 SPRUCEDALE DR
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City | WATERBURY
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State | CT
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Zip | 06706-2838
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Country | US
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Telephone | 203-519-0503
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Fax |
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Authorized Official
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Title or Position | COFOUNDER
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Name | MR. TERRELL PITTS
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Credential |
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Telephone | 203-519-0503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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