Basic Information
| Provider Information | |||||||||
| NPI: | 1346228905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENERATIONS FAMILY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | ARVIND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8604507456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 0228 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | 0404 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 0374 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | .321 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 0467 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QH0100X | 0228 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM0801X | 0467 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | 0228 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004235687 | 05 | CT | MEDICAID | 004235695 | 05 | CT | MEDICAID | 008003942 | 05 | CT | MEDICAID |