Basic Information
| Provider Information | |||||||||
| NPI: | 1336599497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED CENTER FOR NURSING & REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 DAVENPORT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037891650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2016 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | SALAMON | ||||||||
| AuthorizedOfficialFirstName: | MENAJEM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7188826400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2378 | CT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000323 | 05 | CT | MEDICAID |