Provider Demographics
NPI:1528434115
Name:PREVENTATIVE HEALTHCARE SOLUTIONS LLC
Entity type:Organization
Organization Name:PREVENTATIVE HEALTHCARE SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:SEPULVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-870-8008
Mailing Address - Street 1:1187 BROAD ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4101
Mailing Address - Country:US
Mailing Address - Phone:203-870-8008
Mailing Address - Fax:203-330-8007
Practice Address - Street 1:1187 BROAD ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4101
Practice Address - Country:US
Practice Address - Phone:203-870-8008
Practice Address - Fax:203-330-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100262848OtherMEDICARE PTAN