MEDICARE: MATTATUCK HEALTH CARE FACILITY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	144-RH	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609863737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTATUCK HEALTH CARE FACILITY, INC.

Provider Business Mailing Address
First Line	:	9 CLIFF ST
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06710-2125
Country	:	US
Telephone Number	:	203-573-9924
Fax Number	:	203-573-0201

Provider Business Practice Location Address
First Line	:	9 CLIFF ST
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06710-2125
Country	:	US
Telephone Number	:	203-573-9924
Fax Number	:	203-573-0201

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ALLEN V DESENA
Credential	:
Telephone Number	:	203-573-9924

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	04/11/2014

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