=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780190272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEGANT CLINICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2017
-----------------------------------------------------
Last Update Date | 12/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 NORTH RD
-----------------------------------------------------
City | EAST WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06088-9678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-413-9509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 NORTH RD
-----------------------------------------------------
City | EAST WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06088-9678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KAREN KORA GASTON
-----------------------------------------------------
Credential | ED.D.
-----------------------------------------------------
Telephone | 860-758-4098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------