1497054316 NPI number — EASTER SEAL REHABILITATION CENTER

Table of content: (NPI 1497054316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497054316 NPI number — EASTER SEAL REHABILITATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTER SEAL REHABILITATION CENTER
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:
1497054316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 TOMPKINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-1496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-754-5141
Provider Business Mailing Address Fax Number:
203-757-1198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 TOMPKINS ST
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:
06708-1496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-754-5141
Provider Business Practice Location Address Fax Number:
203-757-1198
Provider Enumeration Date:
03/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NIELSEN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/COO
Authorized Official Telephone Number:
203-754-5141

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 12DME0601CT01 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 232000 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017500 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 5376280 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5617574 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 800009105CT01 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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