Provider Demographics
NPI:1700893807
Name:CONNECTICUT RENAISSANCE, INC.
Entity Type:Organization
Organization Name:CONNECTICUT RENAISSANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PENDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-336-5225
Mailing Address - Street 1:350 FAIRFIELD AVE
Mailing Address - Street 2:SUITE 701
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-6014
Mailing Address - Country:US
Mailing Address - Phone:203-336-5225
Mailing Address - Fax:203-226-2851
Practice Address - Street 1:141 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1014
Practice Address - Country:US
Practice Address - Phone:203-602-4441
Practice Address - Fax:203-602-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC-0266261QM0801X
CTSA-0188261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004214277Medicaid
DEC02349Medicare ID - Type Unspecified