Provider Demographics
NPI:1821537648
Name:RESILIENT LIVING PC
Entity Type:Organization
Organization Name:RESILIENT LIVING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-628-9000
Mailing Address - Street 1:1261 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1750
Mailing Address - Country:US
Mailing Address - Phone:860-628-9000
Mailing Address - Fax:
Practice Address - Street 1:1261 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1750
Practice Address - Country:US
Practice Address - Phone:860-628-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030589207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1043293780Medicaid
CT1043293780Medicaid