Provider Demographics
NPI:1194019018
Name:GLASTONBURY HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:GLASTONBURY HEALTH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/CFT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-628-5514
Mailing Address - Street 1:1175 HEBRON AVE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2478
Mailing Address - Country:US
Mailing Address - Phone:860-659-1905
Mailing Address - Fax:860-652-3055
Practice Address - Street 1:1175 HEBRON AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2478
Practice Address - Country:US
Practice Address - Phone:860-659-1905
Practice Address - Fax:860-652-3055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA HEALTH CARE ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2028-C261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020280Medicaid
CT075316Medicare UPIN