1396899282 NPI number — TRACEY JEANNETTE WILES DO

Table of content: TRACEY JEANNETTE WILES DO (NPI 1396899282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396899282 NPI number — TRACEY JEANNETTE WILES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILES
Provider First Name:
TRACEY
Provider Middle Name:
JEANNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396899282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06095-6190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-709-5935
Provider Business Mailing Address Fax Number:
203-709-5942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1598 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06790-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-489-8444
Provider Business Practice Location Address Fax Number:
860-496-8641
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  000270 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5002704 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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