Healthcare Provider Details

I. General information

NPI: 1972723963
Provider Name (Legal Business Name): ATHENA MEADOWBROOK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 SALMON BROOK ST
GRANBY CT
06035-1842
US

IV. Provider business mailing address

350 SALMON BROOK ST
GRANBY CT
06035-1842
US

V. Phone/Fax

Practice location:
  • Phone: 860-653-9888
  • Fax: 860-653-8938
Mailing address:
  • Phone: 860-653-9888
  • Fax: 860-653-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number2080C
License Number StateCT

VIII. Authorized Official

Name: MRS. JEAN A ROSA
Title or Position: DIRECTOR OF AR
Credential:
Phone: 860-751-3900