Provider Demographics
NPI:1174644926
Name:CONNECTICUT JUNIOR REPUBLIC ASSOCIATION, INC.
Entity Type:Organization
Organization Name:CONNECTICUT JUNIOR REPUBLIC ASSOCIATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-567-9423
Mailing Address - Street 1:550 GOSHEN ROAD
Mailing Address - Street 2:PO BOX 161
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-0161
Mailing Address - Country:US
Mailing Address - Phone:860-567-9423
Mailing Address - Fax:
Practice Address - Street 1:80 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1327
Practice Address - Country:US
Practice Address - Phone:203-757-9939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTSA0189261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health