Provider Demographics
NPI:1851497093
Name:COVENANT HOME, INC. (CONNECTICUT)
Entity Type:Organization
Organization Name:COVENANT HOME, INC. (CONNECTICUT)
Other - Org Name:PILGRIM MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALZAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:52 MISSIONARY ROAD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416
Mailing Address - Country:US
Mailing Address - Phone:860-635-2690
Mailing Address - Fax:860-632-2407
Practice Address - Street 1:52 MISSIONARY ROAD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416
Practice Address - Country:US
Practice Address - Phone:860-635-2690
Practice Address - Fax:860-632-2407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT966-C314000000X
CT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000007260Medicaid
CT0092064OtherICF MEDICAID
CT0092064Medicaid
CT000007260Medicaid