MEDICARE: KETTLE BROOK CARE CENTER LLC

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	2219-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	684	OTHER	CT	BC/BS

General Provider Information

NPI Number	:	1801954219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETTLE BROOK CARE CENTER LLC

Provider Business Mailing Address
First Line	:	96 PROSPECT HILL RD
Second Line	:
City	:	EAST WINDSOR
State	:	CT
Zip	:	06088-9668
Country	:	US
Telephone Number	:	860-623-9846
Fax Number	:	860-292-1887

Provider Business Practice Location Address
First Line	:	96 PROSPECT HILL RD
Second Line	:
City	:	EAST WINDSOR
State	:	CT
Zip	:	06088-9668
Country	:	US
Telephone Number	:	860-623-9846
Fax Number	:	860-292-1887

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. CHRISTOPHER S WRIGHT
Credential	:
Telephone Number	:	860-570-2140

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	09/03/2020

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