Provider Demographics
NPI:1124488432
Name:CONNECTICUT PROVIDER OF HOME CARE L.L.C.
Entity type:Organization
Organization Name:CONNECTICUT PROVIDER OF HOME CARE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-792-2273
Mailing Address - Street 1:208 GREENWOOD AVE
Mailing Address - Street 2:UNIT 10
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2130
Mailing Address - Country:US
Mailing Address - Phone:203-792-2273
Mailing Address - Fax:203-826-7887
Practice Address - Street 1:208 GREENWOOD AVE
Practice Address - Street 2:UNIT 10
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2130
Practice Address - Country:US
Practice Address - Phone:203-792-2273
Practice Address - Fax:203-826-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization