Healthcare Provider Details

I. General information

NPI: 1497054316
Provider Name (Legal Business Name): EASTER SEAL REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 TOMPKINS ST
WATERBURY CT
06708-1496
US

IV. Provider business mailing address

22 TOMPKINS ST
WATERBURY CT
06708-1496
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-5141
  • Fax: 203-757-1198
Mailing address:
  • Phone: 203-754-5141
  • Fax: 203-757-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY NIELSEN
Title or Position: CFO/COO
Credential:
Phone: 203-754-5141