Provider Demographics
NPI:1285650481
Name:ADVANTAGE HOME MEDICAL LLC
Entity Type:Organization
Organization Name:ADVANTAGE HOME MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUDON
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:860-963-1208
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-0474
Mailing Address - Country:US
Mailing Address - Phone:860-963-1208
Mailing Address - Fax:860-963-1209
Practice Address - Street 1:213 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1835
Practice Address - Country:US
Practice Address - Phone:860-963-1208
Practice Address - Fax:860-963-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCSW0001408332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA2898055OtherOXFORD HEALTH PLAN
CT004228179Medicaid
CT12DME0789CT02OtherANTHEM
CTCV7876OtherHEALTHNET
CT004228179Medicaid