=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275987802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMINGTON IMAGING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2016
-----------------------------------------------------
Last Update Date | 11/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 FARMINGTON AVE LOWR 1
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-289-3375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 FOUNDERS PLZ STE 400
-----------------------------------------------------
City | EAST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06108-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-289-3375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, MEDICAL STAFF OFFICE
-----------------------------------------------------
Name | MRS. CRYSTAL HOUSH KOLLMORGEN
-----------------------------------------------------
Credential | RT (R) CT
-----------------------------------------------------
Telephone | 860-291-6517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------