Basic Information
Provider Information | |||||||||
NPI: | 1215979810 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH RESOURCES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 WATERSIDE XING STE 401 | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | CT | ||||||||
PostalCode: | 060951588 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607315522 | ||||||||
FaxNumber: | 8607315536 | ||||||||
Practice Location | |||||||||
Address1: | 2 WATERSIDE XING STE 401 | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | CT | ||||||||
PostalCode: | 060951588 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607315522 | ||||||||
FaxNumber: | 8607315536 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2006 | ||||||||
LastUpdateDate: | 10/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENNEDY | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 8606973364 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | OPCC-73 | CT | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 320800000X |   |   | N |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 004249654 | 05 | CT |   | MEDICAID |