Basic Information
| Provider Information | |||||||||
| NPI: | 1497307573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCOMMUNITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FOUNDERS PLZ STE 1802 | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061088301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 828 SULLIVAN AVE FL 1 | ||||||||
| Address2: | |||||||||
| City: | SOUTH WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060742093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605695900 | ||||||||
| FaxNumber: | 8603102127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2019 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | BEAUREGARD | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8605695900 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERCOMMUNITY, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.