Healthcare Provider Details

I. General information

NPI: 1861456840
Provider Name (Legal Business Name): VILLAGE MANOR INC BANKRUPTCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 WINDSOR AVENUE
PLAINFIELD CT
06374
US

IV. Provider business mailing address

16 WINDSOR AVENUE
PLAINFIELD CT
06374
US

V. Phone/Fax

Practice location:
  • Phone: 860-564-4081
  • Fax: 860-564-1472
Mailing address:
  • Phone: 860-564-4081
  • Fax: 860-564-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2003-C
License Number StateCT

VII. Legacy identifiers

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

# 1
Identifier000020032
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 2
Identifier#20032
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: TIMOTHY JOHN COBURN
Title or Position: ADMINISTRATOR/MANAGER
Credential:
Phone: 860-564-4081