=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790154953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2015
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 HIGHLAND AVE
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-2565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-599-5462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 HIGHLAND AVE
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-2565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-599-5462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL PARTNER
-----------------------------------------------------
Name | KHUBAIB SAEED MANSORI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-599-5462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 025900
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------