1083607543 NPI number — BROOK HOLLOW HEALTH CARE CENTER LLC

Table of content: (NPI 1083607543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083607543 NPI number — BROOK HOLLOW HEALTH CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOK HOLLOW HEALTH CARE CENTER 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:
Provider Other Organization Name Type Code:
6
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:
1083607543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
538 PRESTON AVE
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:
55 KONDRACKI LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-4951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-265-6771
Provider Business Practice Location Address Fax Number:
203-284-3883
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2223-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: 000020149 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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