Basic Information
| Provider Information | |||||||||
| NPI: | 1689081085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRENATAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4131 | ||||||||
| Address2: | |||||||||
| City: | YALESVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064921481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032841340 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604566821 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | MACKIE | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE/CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8604566821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINDHAM COMMUNITY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0061 | CT | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HOSPITAL LICENSE NUM | 01 | 0061 | OTHER |