=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124097829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARTFORD HEALTHCARE LABORATORIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 04/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 PATRICIA M GENOVA DR
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-696-8010
-----------------------------------------------------
Fax | 860-665-1979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 PATRICIA M GENOVA DR
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-696-8010
-----------------------------------------------------
Fax | 860-665-1979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REVENUE CYCLE DIRECTOR
-----------------------------------------------------
Name | MS. TEENA M HYATT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-696-8227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CL-0385
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------