Provider Demographics
NPI:1972723963
Name:ATHENA MEADOWBROOK, LLC
Entity type:Organization
Organization Name:ATHENA MEADOWBROOK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:350 SALMON BROOK ST
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-1842
Mailing Address - Country:US
Mailing Address - Phone:860-653-9888
Mailing Address - Fax:860-653-8938
Practice Address - Street 1:350 SALMON BROOK ST
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-1842
Practice Address - Country:US
Practice Address - Phone:860-653-9888
Practice Address - Fax:860-653-8938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2080C313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0095225Medicaid