Provider Demographics
NPI:1922183268
Name:ENFIELD AMBULATORY CARE CENTER LLC
Entity Type:Organization
Organization Name:ENFIELD AMBULATORY CARE CENTER LLC
Other - Org Name:ENFIELD AMBULATORY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ARBULU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-745-1684
Mailing Address - Street 1:15 PALOMBA DRIVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-745-1684
Mailing Address - Fax:860-741-5228
Practice Address - Street 1:15 PALOMBA DRIVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-745-1684
Practice Address - Fax:860-741-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT68WLKN003CT01OtherANTHEM BCBS
991094OtherCONNECTICARE
C02950Medicare ID - Type Unspecified