Provider Demographics
NPI:1023016961
Name:341 JORDAN LANE OPERATING COMPANY II LLC
Entity Type:Organization
Organization Name:341 JORDAN LANE OPERATING COMPANY II LLC
Other - Org Name:WETHERSFIELD HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4004
Mailing Address - Street 1:341 JORDAN LANE
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1128
Mailing Address - Country:US
Mailing Address - Phone:860-563-0101
Mailing Address - Fax:860-257-6107
Practice Address - Street 1:341 JORDAN LANE
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1128
Practice Address - Country:US
Practice Address - Phone:860-563-0101
Practice Address - Fax:860-257-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2283314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE075058Medicare ID - Type Unspecified