1417942491 NPI number — WOLCOTT VIEW MANOR, INC.

Table of content: (NPI 1417942491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417942491 NPI number — WOLCOTT VIEW MANOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOLCOTT VIEW MANOR, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417942491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 BEACH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOLCOTT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06716-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-879-8066
Provider Business Mailing Address Fax Number:
203-879-8072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOLCOTT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06716-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-879-8066
Provider Business Practice Location Address Fax Number:
203-879-8072
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CLEARY, JR.
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
203-879-8066

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  972-C , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000009720 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com