Basic Information
| Provider Information | |||||||||
| NPI: | 1730580325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINIC 21 OF CONNECTICUT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 DRESSLER RD NW | ||||||||
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| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934443 | ||||||||
| FaxNumber: | 3304938677 | ||||||||
| Practice Location | |||||||||
| Address1: | 497 WESTPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068514411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032764888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | ZYNIEWICZ | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3304934443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.