Provider Demographics
NPI:1376585935
Name:CONNECTICUT HEALTH CARE GROUP, LLC
Entity Type:Organization
Organization Name:CONNECTICUT HEALTH CARE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-657-0764
Mailing Address - Street 1:300 HEBRON AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2176
Mailing Address - Country:US
Mailing Address - Phone:860-657-0764
Mailing Address - Fax:
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-657-0764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE54785Medicare UPIN