Provider Demographics
NPI:1083665988
Name:ODD FELLOWS HOME OF CONNECTICUT
Entity Type:Organization
Organization Name:ODD FELLOWS HOME OF CONNECTICUT
Other - Org Name:FAIRVIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-445-7478
Mailing Address - Street 1:235 LESTERTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-445-7478
Mailing Address - Fax:
Practice Address - Street 1:235 LESTERTOWN ROAD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-7478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT258C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000002584Medicaid