=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437659091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREE OF LIFE PRIMARY CARE AND RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 02/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 CHURCH ST STE 417
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-785-7452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 CHURCH ST STE 417
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-785-7452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. RONICA MUKERJEE
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 646-785-7452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------