Provider Demographics
NPI:1750363610
Name:BRONCHO DOSE LTD
Entity type:Organization
Organization Name:BRONCHO DOSE LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LICAMELE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:203-375-8000
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-0520
Mailing Address - Country:US
Mailing Address - Phone:203-375-8000
Mailing Address - Fax:800-784-5430
Practice Address - Street 1:55 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-7135
Practice Address - Country:US
Practice Address - Phone:203-375-8000
Practice Address - Fax:800-784-5430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1732332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC6778635OtherDEA
UT=========003Medicaid
0272150001Medicare ID - Type Unspecified