Provider Demographics
NPI:1588681373
Name:CONSTITUTION SURGERY CENTER EAST LLC
Entity type:Organization
Organization Name:CONSTITUTION SURGERY CENTER EAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-667-1815
Mailing Address - Street 1:100 AVON MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4703
Mailing Address - Country:US
Mailing Address - Phone:860-667-1815
Mailing Address - Fax:860-838-6480
Practice Address - Street 1:174 CROSS RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1215
Practice Address - Country:US
Practice Address - Phone:860-701-0140
Practice Address - Fax:860-701-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0272261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004219475Medicaid
CT490000227Medicare UPIN