Organization
MASONICARE HEALTH CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JON-PAUL VENOIT (PRESIDENT & CEO)
(203) 679-5000
Entity
Organization
Contact information
Practice address
22 MASONIC AVE, WALLINGFORD, CT 06492-3048
(203) 679-5900
Mailing address
22 MASONIC AVE, WALLINGFORD, CT 06492-3048
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
0075
CT
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
0075
CT
261QC1500X
Community Health Clinic/Center
0075
CT
335E00000X
Prosthetic/Orthotic Supplier
0075
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004014791
—
CT
05
—
004025425
—
CT
05
—
0070177
—
CT
01
—
082
BLUE CROSS
CT
Enumeration date
02/15/2006
Last updated
11/05/2019
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