Provider Demographics
NPI:1073594511
Name:CPL PARK MANOR LLC
Entity Type:Organization
Organization Name:CPL PARK MANOR LLC
Other - Org Name:PARK MANOR NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCILLIA
Authorized Official - Suffix:
Authorized Official - Credentials:LLC MANAGER
Authorized Official - Phone:203-608-6100
Mailing Address - Street 1:538 PRESTON AVENUE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4851
Mailing Address - Country:US
Mailing Address - Phone:203-608-6100
Mailing Address - Fax:203-639-3574
Practice Address - Street 1:23 PARK PLACE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3513
Practice Address - Country:US
Practice Address - Phone:973-743-7772
Practice Address - Fax:973-743-8053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ060716314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
315373Medicare Oscar/Certification
1073594511Medicare PIN
NJ315373Medicare Oscar/Certification