=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952514986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOTHILLS FAMILY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 10/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 LITCHFIELD ST
-----------------------------------------------------
City | TORRINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06790-6268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-626-8859
-----------------------------------------------------
Fax | 860-489-7250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 780 LITCHFIELD ST
-----------------------------------------------------
City | TORRINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06790-6268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-626-8859
-----------------------------------------------------
Fax | 860-489-7250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DMITRY ALEX DRAPACH
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 860-626-8859
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 044942
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------