Provider Demographics
NPI:1912156845
Name:CONNECTICUT KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:CONNECTICUT KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ONOFRIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-799-1252
Mailing Address - Street 1:240 INDIAN RIVER RD
Mailing Address - Street 2:SUITE A5
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3649
Mailing Address - Country:US
Mailing Address - Phone:203-799-1252
Mailing Address - Fax:203-799-3252
Practice Address - Street 1:240 INDIAN RIVER RD
Practice Address - Street 2:SUITE A5
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3649
Practice Address - Country:US
Practice Address - Phone:203-799-1252
Practice Address - Fax:203-799-1252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONNECTICUT KIDNEY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-16
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002231Medicaid
CT008002231Medicaid