1922092089 NPI number — CHURCH HOMES, INC. CONGREGATIONAL

Table of content: (NPI 1922092089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922092089 NPI number — CHURCH HOMES, INC. CONGREGATIONAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHURCH HOMES, INC. CONGREGATIONAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVERY HEIGHTS HOME HEALTH AGENCY
Provider Other Organization Name Type Code:
3
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:
1922092089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 AVERY HTS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06106-4271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-527-9126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 NEW BRITAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-527-4663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GILLAND
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
860-527-9126

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  C9206305 , 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: 004116308 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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