Provider Demographics
NPI:1780048280
Name:UC OF MOHEGAN LAKE, LLC
Entity type:Organization
Organization Name:UC OF MOHEGAN LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENKARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-885-0808
Mailing Address - Street 1:3085 E MAIN ST STE 12A
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1542
Mailing Address - Country:US
Mailing Address - Phone:914-358-9612
Mailing Address - Fax:
Practice Address - Street 1:2928 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1007
Practice Address - Country:US
Practice Address - Phone:860-657-8289
Practice Address - Fax:203-905-6824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100138498Medicare PIN