MEDICARE: LUTHERAN HOME OF SOUTHBURY 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	699C	CT

General Provider Information

NPI Number	:	1376543751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUTHERAN HOME OF SOUTHBURY INC

Provider Business Mailing Address
First Line	:	990 MAIN ST N
Second Line	:
City	:	SOUTHBURY
State	:	CT
Zip	:	06488-1267
Country	:	US
Telephone Number	:	203-264-9135
Fax Number	:	203-262-6714

Provider Business Practice Location Address
First Line	:	990 MAIN ST N
Second Line	:
City	:	SOUTHBURY
State	:	CT
Zip	:	06488-1267
Country	:	US
Telephone Number	:	203-264-9135
Fax Number	:	203-262-6714

Authorized Official
Title or Position	:	CEO ADMINISTRATOR
Name	:	MR. WESLEY BARD
Credential	:
Telephone Number	:	203-264-9135

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	11/27/2007

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Directions to “LUTHERAN HOME OF SOUTHBURY INC ” Practice Location

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