Basic Information
| Provider Information | |||||||||
| NPI: | 1265425136 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MASONICARE HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 MASONIC AVE | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064923048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036795900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 MASONIC AVE | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064923048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036795900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | VENOIT | ||||||||
| AuthorizedOfficialFirstName: | JON-PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 2036795000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 119C | CT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 082 | 01 | CT | BLUE CROSS | OTHER | 000001198 | 05 | CT | MEDICAID |