Provider Demographics
NPI:1285690925
Name:CHURCH HOME OF HARTFORD, INC
Entity type:Organization
Organization Name:CHURCH HOME OF HARTFORD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNOWLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-243-6029
Mailing Address - Street 1:200 SEABURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2650
Mailing Address - Country:US
Mailing Address - Phone:860-286-0243
Mailing Address - Fax:860-242-4552
Practice Address - Street 1:200 SEABURY DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2650
Practice Address - Country:US
Practice Address - Phone:860-286-0243
Practice Address - Fax:860-242-4552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHURCH HOME OF HARTFORD, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-21
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2103C314000000X
CT001308376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Single Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000021030Medicaid
CT000021030Medicaid