Provider Demographics
NPI:1255462701
Name:ADULT FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:ADULT FAMILY PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALARZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-269-9778
Mailing Address - Street 1:850 N MAIN ST EXT
Mailing Address - Street 2:BLDG 2 SUITE C2
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-269-9778
Mailing Address - Fax:203-949-1544
Practice Address - Street 1:850 N MAIN ST EXT
Practice Address - Street 2:BLDG 2 SUITE C2
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-269-9778
Practice Address - Fax:203-949-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH11926Medicare UPIN
CTC03414Medicare ID - Type UnspecifiedPRACTICE GROUP NUMBER
CTS50965Medicare UPIN