Provider Demographics
NPI:1144453895
Name:PODIATRY CENTER OF EASTERN CT, LLC
Entity type:Organization
Organization Name:PODIATRY CENTER OF EASTERN CT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-836-2997
Mailing Address - Street 1:360 TOLLAND TPKE STE 2C
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-1770
Mailing Address - Country:US
Mailing Address - Phone:860-647-7727
Mailing Address - Fax:860-647-7559
Practice Address - Street 1:360 TOLLAND TPKE STE 2C
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1770
Practice Address - Country:US
Practice Address - Phone:860-647-7727
Practice Address - Fax:860-647-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000769213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU85602Medicare UPIN
CT6352470001Medicare NSC