Provider Demographics
NPI:1285636548
Name:SCOVILLE PROSTHETICS,INC.
Entity Type:Organization
Organization Name:SCOVILLE PROSTHETICS,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:SHRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:860-247-3209
Mailing Address - Street 1:197 NEW BRITAIN AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3124
Mailing Address - Country:US
Mailing Address - Phone:860-247-3209
Mailing Address - Fax:860-247-1994
Practice Address - Street 1:197 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3124
Practice Address - Country:US
Practice Address - Phone:860-247-3209
Practice Address - Fax:860-247-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12DME0481CT01OtherANTHEN BC/BS OF CT.
CT4012258Medicaid
CT4012258Medicaid