Provider Demographics
NPI:1528047768
Name:INTERIM HEALTHCARE OF NORTH HAVEN, INC.
Entity type:Organization
Organization Name:INTERIM HEALTHCARE OF NORTH HAVEN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-230-4785
Mailing Address - Street 1:278 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2154
Mailing Address - Country:US
Mailing Address - Phone:203-230-4785
Mailing Address - Fax:203-230-4791
Practice Address - Street 1:278 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2154
Practice Address - Country:US
Practice Address - Phone:203-230-4785
Practice Address - Fax:203-230-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0006332U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221545Medicaid
CT004222759Medicaid