Healthcare Provider Details

I. General information

NPI: 1962581199
Provider Name (Legal Business Name): LIBERTY HALL NURSING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BROADWAY ST
COLCHESTER CT
06415-1002
US

IV. Provider business mailing address

36 BROADWAY ST
COLCHESTER CT
06415-1002
US

V. Phone/Fax

Practice location:
  • Phone: 860-537-4606
  • Fax: 860-537-7007
Mailing address:
  • Phone: 860-537-4606
  • Fax: 860-537-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1090-C
License Number StateCT

VIII. Authorized Official

Name: MR. RYAN A VESS
Title or Position: CFO, APPLE HEALTH CARE, INC.
Credential:
Phone: 860-678-9755