Provider Demographics
NPI:1609393909
Name:ODD FELLOWS HOME OF CONNECTICUT
Entity Type:Organization
Organization Name:ODD FELLOWS HOME OF CONNECTICUT
Other - Org Name:FAIRVIEWFIRST
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-445-7478
Mailing Address - Street 1:235 LESTERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2808
Mailing Address - Country:US
Mailing Address - Phone:860-445-7478
Mailing Address - Fax:
Practice Address - Street 1:235 LESTERTOWN RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2808
Practice Address - Country:US
Practice Address - Phone:860-445-7478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ODD FELLOWS HOME OF CONNECTICUT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation