Healthcare Provider Details

I. General information

NPI: 1174516041
Provider Name (Legal Business Name): MASONICARE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 MASONIC AVE
WALLINGFORD CT
06492-3048
US

IV. Provider business mailing address

22 MASONIC AVE
WALLINGFORD CT
06492-3048
US

V. Phone/Fax

Practice location:
  • Phone: 203-679-5900
  • Fax:
Mailing address:
  • Phone: 203-679-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: JON-PAUL VENOIT
Title or Position: PRESIDENT & CEO
Credential:
Phone: 203-679-5000