Healthcare Provider Details

I. General information

NPI: 1760633366
Provider Name (Legal Business Name): 915 ELLA T GRASSO BOULEVARD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 ELLA T GRASSO BLVD
NEW HAVEN CT
06519-5516
US

IV. Provider business mailing address

915 ELLA T GRASSO BLVD
NEW HAVEN CT
06519-5516
US

V. Phone/Fax

Practice location:
  • Phone: 203-865-5155
  • Fax: 203-865-5799
Mailing address:
  • Phone: 203-865-5155
  • Fax: 203-865-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2254
License Number StateCT

VIII. Authorized Official

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