=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922586809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMMAUS HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2018
-----------------------------------------------------
Last Update Date | 08/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 945 MAIN ST STE 205
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-6064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-553-3020
-----------------------------------------------------
Fax | 860-553-3232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 945 MAIN ST STE 205
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-6064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-553-3020
-----------------------------------------------------
Fax | 860-553-3232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KELLY A PFEIFFER
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 860-553-3020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 3886
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------