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General NPI Number Information
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NPI Number | 1679655443
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Entity Type | Organization
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Legal Business Name | CENTRAL CONNECTICUT FOOTCARE CENTER, LLC
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 08/23/2010
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Provider Practice Location Address
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Address Line | 807 BROAD ST.
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City | MERIDEN
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State | CT
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Zip | 06450-3802
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Country | US
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Telephone | 203-238-3668
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Fax | 203-238-3670
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Provider Business Mailing Address
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Address Line | 807 BROAD ST
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City | MERIDEN
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State | CT
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Zip | 06450-4301
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Country | US
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Telephone | 203-238-3668
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Fax | 203-238-3670
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Authorized Official
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Title or Position | OWNER
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Name | DR. TINA ANNE BOUCHER
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Credential | DPM
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Telephone | 203-238-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 000805
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License Number State | CT
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