Provider Demographics
NPI:1992893861
Name:CITY OF BRISTOL
Entity type:Organization
Organization Name:CITY OF BRISTOL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAPKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-584-7050
Mailing Address - Street 1:129 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6272
Mailing Address - Country:US
Mailing Address - Phone:860-584-7050
Mailing Address - Fax:860-584-7967
Practice Address - Street 1:129 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6272
Practice Address - Country:US
Practice Address - Phone:860-584-7050
Practice Address - Fax:860-584-7967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF BRISTOL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2008-07-09
Deactivation Date:2008-06-05
Deactivation Code:
Reactivation Date:2008-07-09
Provider Licenses
StateLicense IDTaxonomies
CT004098639251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004098639Medicaid