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General NPI Number Information
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NPI Number | 1790800480
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Entity Type | Organization
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Legal Business Name | CRV DERMATOLOGY LLC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 113 ELM ST SUITE 200
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City | ENFIELD
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State | CT
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Zip | 06082-3700
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Country | US
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Telephone | 860-741-2225
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Fax | 860-741-2229
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Provider Business Mailing Address
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Address Line | 113 ELM ST SUITE 200
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City | ENFIELD
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State | CT
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Zip | 06082-3700
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Country | US
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Telephone | 860-741-2225
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Fax | 860-741-2229
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Authorized Official
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Title or Position | PRESIDENT OWNER
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Name | MS. DARLENE MARIE HAVILAND
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Credential | PAC
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Telephone | 860-741-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 001494
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License Number State | CT
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