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General NPI Number Information
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NPI Number | 1316559248
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Entity Type | Organization
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Legal Business Name | AGAPE FAMILY MEDICAL CENTER LLC
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Dates
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Enumeration Date | 08/21/2020
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Last Update Date | 08/21/2020
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Provider Practice Location Address
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Address Line | 1078 W MAIN ST STE 3
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City | WATERBURY
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State | CT
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Zip | 06708-2651
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Country | US
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Telephone | 860-797-0572
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Fax |
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Provider Business Mailing Address
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Address Line | 4 WOODLAND TRL
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City | ELLINGTON
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State | CT
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Zip | 06029-3890
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Country | US
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Telephone | 860-797-0572
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | FELISTAS MAZHANDU
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Credential | APRN
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Telephone | 860-797-0572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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