Provider Demographics
NPI:1689608697
Name:ADVANCED COLON CARE INC
Entity Type:Organization
Organization Name:ADVANCED COLON CARE INC
Other - Org Name:SHORELINE COLONOSCOPY SUITES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURIZIO
Authorized Official - Middle Name:DOMENICO
Authorized Official - Last Name:NICHELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-395-0554
Mailing Address - Street 1:929 BOSTON POST RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2143
Mailing Address - Country:US
Mailing Address - Phone:860-395-0554
Mailing Address - Fax:860-395-0448
Practice Address - Street 1:929 BOSTON POST RD
Practice Address - Street 2:SUITE 1
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2143
Practice Address - Country:US
Practice Address - Phone:860-395-0554
Practice Address - Fax:860-395-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG57911Medicare UPIN