Healthcare Provider Details

I. General information

NPI: 1740277094
Provider Name (Legal Business Name): WAVENY CARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 FARM RD
NEW CANAAN CT
06840-6626
US

IV. Provider business mailing address

3 FARM RD
NEW CANAAN CT
06840-6626
US

V. Phone/Fax

Practice location:
  • Phone: 203-594-5200
  • Fax: 203-594-5412
Mailing address:
  • Phone: 203-594-5200
  • Fax: 203-594-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number942-C
License Number StateCT

VIII. Authorized Official

Name: JEREMY VICKERS
Title or Position: CEO
Credential:
Phone: 203-594-5316