Basic Information
| Provider Information | |||||||||
| NPI: | 1154318335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEWISH HOME FOR AGED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
| FaxNumber: | 2037870071 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
| FaxNumber: | 2037870071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOUSQUET | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7037891650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 32-C | CT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000323 | 05 | CT | MEDICAID | 71-01006 | 01 | CT | EVERCARE HMO | OTHER | 706 | 01 | CT | ANTHEM BC/BS OF CT | OTHER |