Provider Demographics
NPI:1710156849
Name:STATE OF CONNECTICUT HEALTH CENTER
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT HEALTH CENTER
Other - Org Name:DURABLE MEDICAL EQUIPMENT & MEDICAL SUPPLIES
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAFRENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-679-7503
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT - DOWLING SOUTH
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:850 BOLTON RD
Practice Address - Street 2:U-85
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-9020
Practice Address - Country:US
Practice Address - Phone:860-486-2629
Practice Address - Fax:860-486-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032452332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies