Healthcare Provider Details

I. General information

NPI: 1912382185
Provider Name (Legal Business Name): 23 FAIR STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 FAIR ST
BRISTOL CT
06010-5531
US

IV. Provider business mailing address

23 FAIR ST
BRISTOL CT
06010-5531
US

V. Phone/Fax

Practice location:
  • Phone: 860-589-2923
  • Fax: 860-589-2924
Mailing address:
  • Phone: 860-589-2923
  • Fax: 860-589-2924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number00000
License Number StateCT

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742