Provider Demographics
NPI:1316559248
Name:AGAPE FAMILY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:AGAPE FAMILY MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FELISTAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZHANDU
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-797-0572
Mailing Address - Street 1:4 WOODLAND TRL
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3890
Mailing Address - Country:US
Mailing Address - Phone:860-797-0572
Mailing Address - Fax:
Practice Address - Street 1:1078 W MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2651
Practice Address - Country:US
Practice Address - Phone:860-797-0572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty