1912952359 NPI number — MARATHON HEALTHCARE CENTER OF WATERBURY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912952359 NPI number — MARATHON HEALTHCARE CENTER OF WATERBURY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARATHON HEALTHCARE CENTER OF WATERBURY 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:
MARATHON HEALTHCARE CENTER OF WATERBURY LLC
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:
1912952359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 EAST RIVER DR.
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
EAST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06108-3288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-289-8762
Provider Business Mailing Address Fax Number:
860-528-5711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 WHITEWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-757-9491
Provider Business Practice Location Address Fax Number:
203-757-4329
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BELMONTE
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
RECEIVER
Authorized Official Telephone Number:
860-644-6780

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2326 , 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: 000009001 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00312170 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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