Provider Demographics
NPI:1679655443
Name:CENTRAL CONNECTICUT FOOTCARE CENTER, LLC
Entity Type:Organization
Organization Name:CENTRAL CONNECTICUT FOOTCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-238-3668
Mailing Address - Street 1:807 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4301
Mailing Address - Country:US
Mailing Address - Phone:203-238-3668
Mailing Address - Fax:203-238-3670
Practice Address - Street 1:807 BROAD ST.
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3802
Practice Address - Country:US
Practice Address - Phone:203-238-3668
Practice Address - Fax:203-238-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000805213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTV06988Medicare UPIN
CT5939420001Medicare NSC