=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275609398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINTONVILLE MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 11/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 CLINTONVILLE RD
-----------------------------------------------------
City | NORTH HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06473-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-239-8017
-----------------------------------------------------
Fax | 203-234-0758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 CLINTONVILLE RD
-----------------------------------------------------
City | NORTH HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06473-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-239-8017
-----------------------------------------------------
Fax | 203-234-0758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DANIEL D SIMONETTI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-239-8017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 183-RH
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------