=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063617397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRATFORD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6911 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06614-1360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-380-0006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 S 4TH ST SUITE 1900
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-779-7512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTS RECEIVABLE SUPERVISOR
-----------------------------------------------------
Name | MRS. RACHELLE K BECKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-779-7512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------