Provider Demographics
NPI:1255711107
Name:EASTER SEALS CAPITOL REGION AND EASTERN CONNECTICUT
Entity type:Organization
Organization Name:EASTER SEALS CAPITOL REGION AND EASTERN CONNECTICUT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-270-0600
Mailing Address - Street 1:100 DEERFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095
Mailing Address - Country:US
Mailing Address - Phone:860-270-0600
Mailing Address - Fax:
Practice Address - Street 1:100 DEERFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095
Practice Address - Country:US
Practice Address - Phone:860-270-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3455261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local