Healthcare Provider Details

I. General information

NPI: 1275918443
Provider Name (Legal Business Name): 55 KONDRACKI LANE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 KONDRACKI LN
WALLINGFORD CT
06492-4951
US

IV. Provider business mailing address

55 KONDRACKI LN
WALLINGFORD CT
06492-4951
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-6771
  • Fax: 203-265-6772
Mailing address:
  • Phone: 203-265-6771
  • Fax: 203-265-6772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number00000
License Number StateCT

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742