1437175932 NPI number — LEDGECREST HEALTH CARE CENTER INC.

Table of content: (NPI 1437175932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437175932 NPI number — LEDGECREST HEALTH CARE CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEDGECREST HEALTH CARE CENTER 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:
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:
1437175932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 KENSINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENSINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06037-2602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-828-0583
Provider Business Mailing Address Fax Number:
860-828-4946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 KENSINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENSINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06037-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-828-0583
Provider Business Practice Location Address Fax Number:
860-828-4946
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VESS
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
860-678-9755

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2046C , 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: 000020462 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808 . This is a "BC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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