Provider Demographics
NPI:1669669073
Name:FAMILY HEALTH AND WELLNESS CENTER OF BRIDGEPORT, LLC
Entity Type:Organization
Organization Name:FAMILY HEALTH AND WELLNESS CENTER OF BRIDGEPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-372-9002
Mailing Address - Street 1:4699 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1830
Mailing Address - Country:US
Mailing Address - Phone:203-372-9002
Mailing Address - Fax:203-372-6747
Practice Address - Street 1:4699 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1830
Practice Address - Country:US
Practice Address - Phone:203-372-9002
Practice Address - Fax:203-372-6747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-29
Last Update Date:2007-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041401261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH86007Medicare UPIN