=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477674182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST LAKE PROPERTIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W LAKE AVE
-----------------------------------------------------
City | GUILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06437-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-488-9142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 W LAKE AVE
-----------------------------------------------------
City | GUILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06437-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CATHLEEN O'CONNOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-488-9142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------