Provider Demographics
NPI:1235214826
Name:THE HOPE CLINIC, LLC
Entity Type:Organization
Organization Name:THE HOPE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TJAN-WETTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-589-4673
Mailing Address - Street 1:10 N MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-8102
Mailing Address - Country:US
Mailing Address - Phone:860-589-4673
Mailing Address - Fax:860-589-6124
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-8102
Practice Address - Country:US
Practice Address - Phone:860-589-4673
Practice Address - Fax:860-589-6124
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HOPE CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5114720001Medicare NSC
CTC03196Medicare PIN