Provider Demographics
NPI:1588691448
Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-377-5117
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 HAWLEY LANE
Practice Address - Street 2:SUITE 1101
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1204
Practice Address - Country:US
Practice Address - Phone:203-377-5117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004177699Medicaid
15047OtherG2
651-YIOtherG2
098690OtherG2
027336OtherG2
113414024HOtherG2
801438OtherG2
116529OtherG2
013100POtherG2
60-00178OtherG2
ANC015OtherG2
335394OtherG2
728069OtherG2
077218OtherG2
1020022OtherG2
40437580000OtherG2
4072971OtherG2
15047OtherG2
=========OtherG2
728069OtherG2