Provider Demographics
NPI:1922500412
Name:CENTER FOR DIABETES EXCELLENCE
Entity Type:Organization
Organization Name:CENTER FOR DIABETES EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:HICKEY
Authorized Official - Last Name:AHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:203-261-4277
Mailing Address - Street 1:530 SCENIC RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-2127
Mailing Address - Country:US
Mailing Address - Phone:203-909-0016
Mailing Address - Fax:
Practice Address - Street 1:500 PURDY HILL RD STE 2
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-1661
Practice Address - Country:US
Practice Address - Phone:203-261-4277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14252080P0205X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty