=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366687790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERICARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2008
-----------------------------------------------------
Last Update Date | 02/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 WOLCOTT RD
-----------------------------------------------------
City | WOLCOTT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06716-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-633-4560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 WOLCOTT RD
-----------------------------------------------------
City | WOLCOTT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06716-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-633-4560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JONATHAN J BRENES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-910-7533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------