Basic Information
| Provider Information | |||||||||
| NPI: | 1780824854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENIOR CARE CENTERS OF CONNECTICUT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SENIOR CARE OF EAST HARTFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 NESHAMINY INTERPLEX | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2156426610 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 MAIN ST | ||||||||
| Address2: | SUITE J | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061183239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605689692 | ||||||||
| FaxNumber: | 8605689698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2009 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | MEHNERT | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2156426600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | 04102009 | CT | Y | Respite Care Facility | Respite Care |
ID Information
| ID | Type | State | Issuer | Description | 004260808 | 05 | CT | MEDICAID |