Healthcare Provider Details

I. General information

NPI: 1851497093
Provider Name (Legal Business Name): COVENANT HOME, INC. (CONNECTICUT)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 MISSIONARY ROAD
CROMWELL CT
06416
US

IV. Provider business mailing address

52 MISSIONARY ROAD
CROMWELL CT
06416
US

V. Phone/Fax

Practice location:
  • Phone: 860-635-2690
  • Fax: 860-632-2407
Mailing address:
  • Phone: 860-635-2690
  • Fax: 860-632-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number966-C
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCT

VIII. Authorized Official

Name: ELIZABETH MALZAHN
Title or Position: VICE PRESIDENT OF HEALTH SERVICES
Credential:
Phone: 773-878-4430