Provider Demographics
NPI:1154313310
Name:CEDAR LANE REHABILITATION & HEALTH CARE CTR LLC
Entity Type:Organization
Organization Name:CEDAR LANE REHABILITATION & HEALTH CARE CTR LLC
Other - Org Name:VILLAGE GREEN OF WATERBURY REHABILITATION AND HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LLC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCILLIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-608-6100
Mailing Address - Street 1:538 PRESTON AVE
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 1:128 CEDAR AVENUE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2700
Practice Address - Country:US
Practice Address - Phone:203-757-9271
Practice Address - Fax:203-757-2988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONNECTICUT SUBACUTE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-15
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2225C314000000X
CT2225-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000520157Medicaid
CT075210001Medicare Oscar/Certification
CT000520157Medicaid