Healthcare Provider Details

I. General information

NPI: 1033931209
Provider Name (Legal Business Name): PENIEL HOMECARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BURBANK RD
ELLINGTON CT
06029-2806
US

IV. Provider business mailing address

101 BURBANK RD
ELLINGTON CT
06029-2806
US

V. Phone/Fax

Practice location:
  • Phone: 860-894-0975
  • Fax:
Mailing address:
  • Phone: 860-402-4857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. JANE ASUMADU
Title or Position: OWNER
Credential:
Phone: 608-894-0975