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General NPI Number Information
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NPI Number | 1497055941
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Entity Type | Organization
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Legal Business Name | STATE OF CONNECTICUT HEALTH CENTER
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Dates
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Enumeration Date | 11/01/2010
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Last Update Date | 11/01/2010
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Provider Practice Location Address
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Address Line | 263 FARMINGTON AVE MC 5386
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City | FARMINGTON
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State | CT
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Zip | 06030-5386
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Country | US
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Telephone | 860-679-5500
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Fax | 860-676-3415
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Provider Business Mailing Address
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Address Line | 263 FARMINGTON AVE MC 5386
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City | FARMINGTON
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State | CT
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Zip | 06030-5386
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Country | US
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Telephone | 860-679-5500
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Fax | 860-676-3415
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Authorized Official
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Title or Position | DIRECTOR OF ADMINISTRATIVE SERVICES
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Name | MS. GAIL JOHNSON
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Credential |
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Telephone | 860-679-5536
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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