Provider Demographics
NPI:1073621579
Name:SHORELINE ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:SHORELINE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR, CORP BUS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-688-2046
Mailing Address - Street 1:100 CHURCH ST S # MCS-2
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1703
Mailing Address - Country:US
Mailing Address - Phone:203-688-2046
Mailing Address - Fax:203-688-8817
Practice Address - Street 1:800 BOSTON POST RD BLDG 1
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2770
Practice Address - Country:US
Practice Address - Phone:203-453-7100
Practice Address - Fax:203-453-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0281261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004247856Medicaid