Provider Demographics
NPI:1811996416
Name:TOWN OF DEEP RIVER
Entity type:Organization
Organization Name:TOWN OF DEEP RIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM SUP
Authorized Official - Prefix:
Authorized Official - First Name:CARMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:860-526-6033
Mailing Address - Street 1:56 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DEEP RIVER
Mailing Address - State:CT
Mailing Address - Zip Code:06417-1932
Mailing Address - Country:US
Mailing Address - Phone:860-526-6033
Mailing Address - Fax:860-526-6085
Practice Address - Street 1:56 HIGH ST
Practice Address - Street 2:
Practice Address - City:DEEP RIVER
Practice Address - State:CT
Practice Address - Zip Code:06417-1932
Practice Address - Country:US
Practice Address - Phone:860-526-6033
Practice Address - Fax:860-526-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC80177251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4043196Medicaid
077114Medicare ID - Type Unspecified