=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649492273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCLEAN FUND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 03/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 GREAT POND RD
-----------------------------------------------------
City | SIMSBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06070-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-653-3700
-----------------------------------------------------
Fax | 860-651-1247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 GREAT POND RD
-----------------------------------------------------
City | SIMSBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06070-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-653-3700
-----------------------------------------------------
Fax | 860-651-1247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP FINANCE
-----------------------------------------------------
Name | MR. AUGUSTO GAUTIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-658-3759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 884-C
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------