Basic Information
Provider Information | |||||||||
NPI: | 1851556930 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TC HEALTHCARE I, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RUTLAND MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 86 JUNIPER LN | ||||||||
Address2: |   | ||||||||
City: | GLASTONBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 060332515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609300091 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 46 NICHOLS ST | ||||||||
Address2: |   | ||||||||
City: | RUTLAND | ||||||||
State: | VT | ||||||||
PostalCode: | 057013275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027754939 | ||||||||
FaxNumber: | 8027732196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2008 | ||||||||
LastUpdateDate: | 07/28/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COBURN | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8609300091 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.