Healthcare Provider Details

I. General information

NPI: 1063604601
Provider Name (Legal Business Name): CLUB STAFFING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 WHIRLWIND HILL RD
WALLINGFORD CT
06492-2727
US

IV. Provider business mailing address

1345 WHIRLWIND HILL RD
WALLINGFORD CT
06492-2727
US

V. Phone/Fax

Practice location:
  • Phone: 561-367-1175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number003103
License Number StateCT

VIII. Authorized Official

Name: MRS. ANNA CORINNE HLADKY
Title or Position: OCCUPATIONAL THERAPIST
Credential:
Phone: 203-915-3376