Basic Information
| Provider Information | |||||||||
| NPI: | 1851402382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT MARY HOME, INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2021 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605708200 | ||||||||
| FaxNumber: | 8605708293 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605708200 | ||||||||
| FaxNumber: | 8605708293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LATOVICK | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 7343436628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 28-RH | CT | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 680C | CT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000090282 | 05 | CT | MEDICAID | 000006809 | 05 | CT | MEDICAID |