Provider Demographics
NPI:1265546956
Name:MANSFIELD FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:MANSFIELD FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL RECORDS
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WYSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-487-0002
Mailing Address - Street 1:34 PROFESSIONAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268
Mailing Address - Country:US
Mailing Address - Phone:860-487-0002
Mailing Address - Fax:860-429-1663
Practice Address - Street 1:34 PROFESSIONAL PARK ROAD
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06268
Practice Address - Country:US
Practice Address - Phone:860-487-0002
Practice Address - Fax:860-429-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID
CT=========OtherTAX ID