Healthcare Provider Details

I. General information

NPI: 1215935127
Provider Name (Legal Business Name): 107 OSBORNE STREET OPERATING COMPANY II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 OSBORNE ST
DANBURY CT
06810-6016
US

IV. Provider business mailing address

107 OSBORNE ST
DANBURY CT
06810-6016
US

V. Phone/Fax

Practice location:
  • Phone: 203-792-8102
  • Fax: 203-731-5306
Mailing address:
  • Phone: 203-792-8102
  • Fax: 203-731-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2276
License Number StateCT

VIII. Authorized Official

Name: KEVIN BRESLIN
Title or Position: EXECUTIVE VP
Credential:
Phone: 201-242-4004