=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952858151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CT HOMECARE PLUS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2016
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 MERIDEN RD 407
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06705-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-300-0633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 MERIDEN RD 407
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06705-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-300-0633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS FEZEKA GLADYS GASA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 203-300-0633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCA.0001164
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------