Basic Information
| Provider Information | |||||||||
| NPI: | 1255711107 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTER SEALS CAPITOL REGION AND EASTERN CONNECTICUT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 DEERFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602700600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 DEERFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602700600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 06/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOUSE | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8602700600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0905X | 3455 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
No ID Information.