Healthcare Provider Details

I. General information

NPI: 1457502924
Provider Name (Legal Business Name): 97 PRESTON ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 PRESTON RD
GRISWOLD CT
06351-2516
US

IV. Provider business mailing address

97 PRESTON RD
GRISWOLD CT
06351-2516
US

V. Phone/Fax

Practice location:
  • Phone: 860-376-4438
  • Fax: 860-376-8343
Mailing address:
  • Phone: 860-376-4438
  • Fax: 860-376-8343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2256
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARCELLA WILKINSON
Title or Position: CORPORATE DIRECTOR
Credential:
Phone: 610-925-4045