Basic Information
| Provider Information | |||||||||
| NPI: | 1053073122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLETCHER ENTERPRISE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLETCHER MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8 SAW MILL LN | ||||||||
| Address2: | |||||||||
| City: | PLAINVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060621572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033797328 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8 SAW MILL LN | ||||||||
| Address2: | |||||||||
| City: | PLAINVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060621572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033797328 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2021 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLETCHER | ||||||||
| AuthorizedOfficialFirstName: | SARETA | ||||||||
| AuthorizedOfficialMiddleName: | KETURAH | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2033797328 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 1306388566 | 01 | CT | NPPES | OTHER |