Healthcare Provider Details

I. General information

NPI: 1205979457
Provider Name (Legal Business Name): COOK WILLOW CONVALESCENT HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 HILLSIDE AVE
PLYMOUTH CT
06782-2305
US

IV. Provider business mailing address

81 HILLSIDE AVE
PLYMOUTH CT
06782-2305
US

V. Phone/Fax

Practice location:
  • Phone: 860-283-8208
  • Fax: 860-283-6667
Mailing address:
  • Phone: 860-283-8208
  • Fax: 860-283-6667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number932-C
License Number StateCT

VIII. Authorized Official

Name: MS. SUSAN A. MACDONALD
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 860-283-8208