Provider Demographics
NPI:1437436169
Name:MEADOWBROOK CENTER INC
Entity Type:Organization
Organization Name:MEADOWBROOK CENTER INC
Other - Org Name:MEADOWBROOK OF GRANBY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVANZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-653-9888
Mailing Address - Street 1:350 SALMON BROOK ST
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-1842
Mailing Address - Country:US
Mailing Address - Phone:860-653-9888
Mailing Address - Fax:860-653-8938
Practice Address - Street 1:350 SALMON BROOK ST
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-1842
Practice Address - Country:US
Practice Address - Phone:860-653-9888
Practice Address - Fax:860-653-8938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2080C261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020800Medicaid
CT000020800Medicaid