Provider Demographics
NPI:1669454674
Name:TOWN OF GRISWOLD
Entity Type:Organization
Organization Name:TOWN OF GRISWOLD
Other - Org Name:GRISWOLD REGIONAL VISITING NURSE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LAROUX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:860-376-7077
Mailing Address - Street 1:68 ASHLAND STREET
Mailing Address - Street 2:
Mailing Address - City:JEWETT CITY
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2310
Mailing Address - Country:US
Mailing Address - Phone:860-376-7077
Mailing Address - Fax:860-376-7081
Practice Address - Street 1:68 ASHLAND STREET
Practice Address - Street 2:
Practice Address - City:JEWETT CITY
Practice Address - State:CT
Practice Address - Zip Code:06351-2310
Practice Address - Country:US
Practice Address - Phone:860-376-7077
Practice Address - Fax:860-376-7081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWN OF GRISWOLD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-16
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC8034251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004043121Medicaid
CT077090Medicare ID - Type Unspecified