Provider Demographics
NPI:1912710781
Name:AGE WELL ALLIANCE
Entity type:Organization
Organization Name:AGE WELL ALLIANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-223-2212
Mailing Address - Street 1:82 GRISWOLD DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1146
Mailing Address - Country:US
Mailing Address - Phone:251-223-2212
Mailing Address - Fax:
Practice Address - Street 1:82 GRISWOLD DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1146
Practice Address - Country:US
Practice Address - Phone:251-223-2212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-27
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing CareGroup - Single Specialty
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care