Provider Demographics
NPI:1043690100
Name:MASONICARE HEALTH CENTER
Entity Type:Organization
Organization Name:MASONICARE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:203-679-5959
Mailing Address - Street 1:22 MASONIC AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3048
Practice Address - Country:US
Practice Address - Phone:203-679-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASONICARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10225314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility