Provider Demographics
NPI:1639225410
Name:UNIVERSITY OF CONNECTICUT
Entity Type:Organization
Organization Name:UNIVERSITY OF CONNECTICUT
Other - Org Name:NAYDEN REHABILITATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:P
Authorized Official - Last Name:VIGNEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-486-8080
Mailing Address - Street 1:843 BOLTON ROAD
Mailing Address - Street 2:U-1249
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06269-1249
Mailing Address - Country:US
Mailing Address - Phone:860-486-8080
Mailing Address - Fax:860-486-8081
Practice Address - Street 1:843 BOLTON ROAD
Practice Address - Street 2:U-1249
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-1249
Practice Address - Country:US
Practice Address - Phone:860-486-8080
Practice Address - Fax:860-486-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076588Medicare Oscar/Certification