Healthcare Provider Details

I. General information

NPI: 1972633436
Provider Name (Legal Business Name): THE MARY WADE HOME, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/27/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CLINTON AVE
NEW HAVEN CT
06513-3100
US

IV. Provider business mailing address

118 CLINTON AVE
NEW HAVEN CT
06513-3100
US

V. Phone/Fax

Practice location:
  • Phone: 203-562-7222
  • Fax: 203-848-6386
Mailing address:
  • Phone: 203-562-7222
  • Fax: 203-848-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1665-RCH
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2051-C
License Number StateCT

VIII. Authorized Official

Name: WILLIAM CHARLES GINTER
Title or Position: CFO
Credential:
Phone: 203-672-7817