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General NPI Number Information
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NPI Number | 1134509615
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Entity Type | Organization
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Legal Business Name | AVON MEDICAL WELLNESS CENTER LLC
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Dates
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Enumeration Date | 06/01/2015
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 540 HOPMEADOW ST
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City | SIMSBURY
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State | CT
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Zip | 06070-2496
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Country | US
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Telephone | 860-272-4646
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Fax | 860-272-4642
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Provider Business Mailing Address
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Address Line | 540 HOPMEADOW ST
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City | SIMSBURY
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State | CT
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Zip | 06070-2496
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Country | US
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Telephone | 860-272-4646
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Fax | 860-272-4642
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. OFER SAGIV
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Credential | MD
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Telephone | 860-272-4646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 001816
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 047333
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License Number State | CT
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