Healthcare Provider Details

I. General information

NPI: 1396189460
Provider Name (Legal Business Name): MASONICARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ARLINGTON DR
AVON CT
06001
US

IV. Provider business mailing address

15 ARLINGTON DR
AVON CT
06001-5119
US

V. Phone/Fax

Practice location:
  • Phone: 203-535-3129
  • Fax:
Mailing address:
  • Phone: 203-535-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number008234
License Number StateCT

VIII. Authorized Official

Name: JESSICA KELLY
Title or Position: RD
Credential:
Phone: 413-313-1468