Provider Demographics
NPI:1497115380
Name:AVON FAMILY HEALTH, LLC
Entity Type:Organization
Organization Name:AVON FAMILY HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:LEAHY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-675-6595
Mailing Address - Street 1:30 W AVON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3678
Mailing Address - Country:US
Mailing Address - Phone:860-675-6595
Mailing Address - Fax:860-673-6721
Practice Address - Street 1:30 W AVON RD
Practice Address - Street 2:SUITE D
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3678
Practice Address - Country:US
Practice Address - Phone:860-675-6595
Practice Address - Fax:860-673-6721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVON PROFESSIONAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-04
Last Update Date:2017-07-20
Deactivation Date:2017-04-19
Deactivation Code:
Reactivation Date:2017-07-20
Provider Licenses
StateLicense IDTaxonomies
CT261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004238003Medicaid
11243173OtherCAQH
1669496113OtherTRICARE
CT11000341OtherGROUP MEDICAID
D400060973OtherMEDICARE PTAN
7327000OtherCIGNA
637238OtherWELLCARE
P4395587OtherOXFORD
1100341OtherGROUP MEDICARE PTAN
1100341OtherGROUP MEDICARE PTAN
CT004238003Medicaid