Healthcare Provider Details

I. General information

NPI: 1144201344
Provider Name (Legal Business Name): SPECTRUM HEALTHCARE DERBY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CHATFIELD ST
DERBY CT
06418-1150
US

IV. Provider business mailing address

210 CHATFIELD ST
DERBY CT
06418-1150
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-5454
  • Fax: 860-871-5757
Mailing address:
  • Phone: 860-871-5454
  • Fax: 860-871-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2236
License Number StateCT

VIII. Authorized Official

Name: DR. HOWARD WILLIAM DICKSTEIN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 860-871-5454