=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417053810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLEBURY CONVALESCENT HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 778 MIDDLEBURY RD
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-758-2471
-----------------------------------------------------
Fax | 203-598-3449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 778 MIDDLEBURY RD
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-758-2471
-----------------------------------------------------
Fax | 203-598-3449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTING MANAGER
-----------------------------------------------------
Name | MRS. CHRISTINE B FEOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-758-2471
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 704-C
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------