Basic Information
| Provider Information | |||||||||
| NPI: | 1306062559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN REHABILITATION NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 WESTERN BOULEVARD SUITE 101 | ||||||||
| Address2: | EASTERN REHABILTATION NETWORK | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606574723 | ||||||||
| FaxNumber: | 8606524340 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 PATRICIA M. GENOVA DRIVE | ||||||||
| Address2: | EASTERN REHABILTATION NETWORK | ||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606675480 | ||||||||
| FaxNumber: | 8606678416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 02/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | PARISI | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8606675480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004212362 | 05 | CT | MEDICAID |