MEDICARE: SHADY KNOLL HEALTH CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	2107-C	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225098643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADY KNOLL HEALTH CENTER, INC

Provider Business Mailing Address
First Line	:	41 SKOKORAT ST
Second Line	:
City	:	SEYMOUR
State	:	CT
Zip	:	06483-3826
Country	:	US
Telephone Number	:	203-881-2555
Fax Number	:	203-881-0853

Provider Business Practice Location Address
First Line	:	41 SKOKORAT ST
Second Line	:
City	:	SEYMOUR
State	:	CT
Zip	:	06483-3826
Country	:	US
Telephone Number	:	203-881-2555
Fax Number	:	203-881-0853

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	LAWRENCE G. SANTILLI
Credential	:
Telephone Number	:	860-751-3900

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	02/16/2023

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