1730451501 NPI number — WADSWORTH GLEN, INC

Table of content: (NPI 1730451501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730451501 NPI number — WADSWORTH GLEN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WADSWORTH GLEN, 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:
1730451501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 BOSTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-346-9299
Provider Business Mailing Address Fax Number:
860-343-5030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 BOSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-346-9299
Provider Business Practice Location Address Fax Number:
860-343-5030
Provider Enumeration Date:
02/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MOSIER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
860-751-3900

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2025C , 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: 000020256 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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