=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932192408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUBACUTE CENTER OF BRISTOL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2005
-----------------------------------------------------
Last Update Date | 05/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 FAIR STREET
-----------------------------------------------------
City | FORESTVILLE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-589-2923
-----------------------------------------------------
Fax | 860-589-3148
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 538 PRESTON AVE SUITE 270
-----------------------------------------------------
City | MERIDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06450-4851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-608-6100
-----------------------------------------------------
Fax | 203-639-3574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LLC MANAGER
-----------------------------------------------------
Name | MS. CAROLE M. SCILLIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-608-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 2224-C
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------