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General NPI Number Information
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NPI Number | 1811426695
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Entity Type | Organization
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Legal Business Name | FAIRFIELD COUNTY HEALTH & WELLNESS SERVICES II LLC
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Dates
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Enumeration Date | 06/06/2017
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Last Update Date | 06/06/2017
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Provider Practice Location Address
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Address Line | 325 REEF ROAD/SUITE 109
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City | FAIRFIELD
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State | CT
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Zip | 06824
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Country | US
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Telephone | 203-955-1821
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Fax | 203-955-1823
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Provider Business Mailing Address
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Address Line | 21 MAPLE RIDGE RD
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City | TRUMBULL
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State | CT
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Zip | 06611-5522
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Country | US
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Telephone | 203-671-3587
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Fax | 203-671-3587
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Authorized Official
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Title or Position | OWNER/MD
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Name | PROF. CARINE JEAN
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Credential | MD
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Telephone | 203-671-3587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | 033954
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 033954
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number | 033954
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License Number State | CT
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