Provider Demographics
NPI:1285629964
Name:THE MORTLAKE FIRE COMPANY OF BROOKLYN CONNECTICUT INC
Entity Type:Organization
Organization Name:THE MORTLAKE FIRE COMPANY OF BROOKLYN CONNECTICUT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:LUCIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODEUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-774-2032
Mailing Address - Street 1:269 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2302
Mailing Address - Country:US
Mailing Address - Phone:860-638-1800
Mailing Address - Fax:860-638-1802
Practice Address - Street 1:12 CANTERBURY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:CT
Practice Address - Zip Code:06234-1902
Practice Address - Country:US
Practice Address - Phone:860-774-2032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
710C019B1CT01OtherBLUE CROSS/BLUE SHIELD
CT004094538Medicaid
590006253OtherRAILROAD MEDICARE
710C019B1CT01OtherBLUE CROSS/BLUE SHIELD