Basic Information
| Provider Information | |||||||||
| NPI: | 1588638688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASONICARE HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 MASONIC AVE | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064923048 | ||||||||
| CountryCode: | US | ||||||||
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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: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | VENOIT | ||||||||
| AuthorizedOfficialFirstName: | JON-PAUL | ||||||||
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| 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 | 261QC1500X | 0075 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261Q00000X | 0075 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | 335E00000X | 0075 | CT | N | Suppliers | Prosthetic/Orthotic Supplier | 261QA1903X | 0075 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 004025425 | 05 | CT | MEDICAID | 0070177 | 05 | CT | MEDICAID | 082 | 01 | CT | BLUE CROSS | OTHER | 004014791 | 05 | CT | MEDICAID |