Healthcare Provider Details

I. General information

NPI: 1861509044
Provider Name (Legal Business Name): ATHENA MIDDLESEX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RANDOLPH RD
MIDDLETOWN CT
06457-5637
US

IV. Provider business mailing address

100 RANDOLPH RD
MIDDLETOWN CT
06457-5637
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-0353
  • Fax: 860-346-1932
Mailing address:
  • Phone: 860-344-0353
  • Fax: 860-346-1932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2263
License Number StateCT

VIII. Authorized Official

Name: LAWRENCE G. SANTILLI
Title or Position: MANAGER
Credential:
Phone: 860-751-3900