Basic Information
| Provider Information | |||||||||
| NPI: | 1891822607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCORE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1579 STRAITS TPKE | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067621835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035772002 | ||||||||
| FaxNumber: | 2035772060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1579 STRAITS TPKE | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067621835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035772002 | ||||||||
| FaxNumber: | 2035772060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | DANE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2035772002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4177318 | 05 | CT | MEDICAID | 004177318 | 05 | CT | MEDICAID |