Provider Demographics
NPI:1154481562
Name:MERCY HOME CARE OF CONNECTICUT LLC
Entity Type:Organization
Organization Name:MERCY HOME CARE OF CONNECTICUT LLC
Other - Org Name:MERCY HOME CARE/MERCY CARES BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREDHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-617-0606
Mailing Address - Street 1:230 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2117
Mailing Address - Country:US
Mailing Address - Phone:203-617-0606
Mailing Address - Fax:203-617-0609
Practice Address - Street 1:230 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2117
Practice Address - Country:US
Practice Address - Phone:203-617-0606
Practice Address - Fax:203-617-0609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCSW.000.3005332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004180593Medicaid
CT004180593OtherWELLCARE MANAGED MEDICAID
CT12DME0964CT01OtherANTHEM BC/BS
CT12DME0964CT01OtherANTHEM BC/BS
CT1201930001Medicare NSC
CT=========OtherUNITED HEALTH CARE