Provider Demographics
NPI:1619527959
Name:CONNECTICUT LIFESTYLE MEDICINE
Entity type:Organization
Organization Name:CONNECTICUT LIFESTYLE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, NURSE
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OROURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-788-6573
Mailing Address - Street 1:955 S MAIN ST # B201
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5153
Mailing Address - Country:US
Mailing Address - Phone:860-788-6573
Mailing Address - Fax:
Practice Address - Street 1:955 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5153
Practice Address - Country:US
Practice Address - Phone:516-993-2847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty