1073594511 NPI number — CPL PARK MANOR LLC

Table of content: (NPI 1073594511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073594511 NPI number — CPL PARK MANOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CPL PARK MANOR LLC
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:
PARK MANOR NURSING AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
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:
1073594511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
538 PRESTON AVENUE
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
MERIDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06450-4851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-608-6100
Provider Business Mailing Address Fax Number:
203-639-3574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 PARK PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07003-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-743-7772
Provider Business Practice Location Address Fax Number:
973-743-8053
Provider Enumeration Date:
11/10/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCILLIA
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
203-608-6100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  060716 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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