MEDICARE: CANDLEWOOD VALLEY PEDIATRICS, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1811021066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANDLEWOOD VALLEY PEDIATRICS, P.C.

Provider Business Mailing Address
First Line	:	120 PARK LANE RD STE A101
Second Line	:
City	:	NEW MILFORD
State	:	CT
Zip	:	06776-2444
Country	:	US
Telephone Number	:	860-355-8190
Fax Number	:	860-355-3856

Provider Business Practice Location Address
First Line	:	120 PARK LANE RD STE A101
Second Line	:
City	:	NEW MILFORD
State	:	CT
Zip	:	06776-2444
Country	:	US
Telephone Number	:	860-355-8190
Fax Number	:	860-355-3856

Authorized Official
Title or Position	:	MANAGED CARE COORDINATOR
Name	:	MRS. MARILYN C DECRESCENZO
Credential	:
Telephone Number	:	860-355-8190

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	08/22/2020

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