Provider Demographics
NPI:1881462232
Name:CONNECTICUT GO GREEN MEDICAL PLLC
Entity type:Organization
Organization Name:CONNECTICUT GO GREEN MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DELORETTA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ECKENRODE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-874-7001
Mailing Address - Street 1:31 CHERRY ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3465
Mailing Address - Country:US
Mailing Address - Phone:203-874-7001
Mailing Address - Fax:203-874-7002
Practice Address - Street 1:31 CHERRY ST
Practice Address - Street 2:UNIT 1
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3465
Practice Address - Country:US
Practice Address - Phone:203-874-7001
Practice Address - Fax:203-874-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty