Provider Demographics
NPI:1659082881
Name:PAIN CENTER OF CT LLC
Entity Type:Organization
Organization Name:PAIN CENTER OF CT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONVERTITO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, DNP
Authorized Official - Phone:203-513-8230
Mailing Address - Street 1:494 BRIDGEPORT AVE
Mailing Address - Street 2:UNIT 101
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:475-269-5555
Mailing Address - Fax:
Practice Address - Street 1:4 RESEARCH DRIVE
Practice Address - Street 2:SUITE 402
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:475-269-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty