=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194069708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTICUT RENAISSANCE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2012
-----------------------------------------------------
Last Update Date | 01/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1126 MAIN ST
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06604-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-333-2040
-----------------------------------------------------
Fax | 203-333-2152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 FAIRFIELD AVE SUITE 701
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06604-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-336-5225
-----------------------------------------------------
Fax | 203-336-2851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOSEPH B RIKER
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 20333652258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 0442
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 0442
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------