Provider Demographics
NPI:1861509044
Name:ATHENA MIDDLESEX LLC
Entity Type:Organization
Organization Name:ATHENA MIDDLESEX LLC
Other - Org Name:MIDDLESEX HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANTILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:100 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5637
Mailing Address - Country:US
Mailing Address - Phone:860-344-0353
Mailing Address - Fax:860-346-1932
Practice Address - Street 1:100 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5637
Practice Address - Country:US
Practice Address - Phone:860-344-0353
Practice Address - Fax:860-346-1932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA HEALTH CARE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-24
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2263314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT827OtherBCBS
CT000009472Medicaid
CT075106Medicare ID - Type Unspecified