Healthcare Provider Details

I. General information

NPI: 1558430256
Provider Name (Legal Business Name): WATERBURY EXTENDED CARE FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BUNKER HILL RD
WATERTOWN CT
06795-3304
US

IV. Provider business mailing address

35 BUNKER HILL RD
WATERTOWN CT
06795-3304
US

V. Phone/Fax

Practice location:
  • Phone: 860-274-5428
  • Fax: 860-945-7034
Mailing address:
  • Phone: 860-274-5428
  • Fax: 860-945-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1082-C
License Number StateCT

VIII. Authorized Official

Name: MR. RYAN VESS
Title or Position: CFO
Credential:
Phone: 860-678-9755