=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144609090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOVEREIGN HOME HEALTH OF CONNECTICUT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 OAKWOOD AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06850-1365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-858-4021
-----------------------------------------------------
Fax | 203-846-4400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 OAKWOOD AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06850-1365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-858-4021
-----------------------------------------------------
Fax | 203-846-4400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SIDNEY KAIN
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 203-858-4021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | HCA.0000886
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------