Provider Demographics
NPI:1215370994
Name:SHADY KNOLL HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:SHADY KNOLL HEALTH CARE CENTER, INC.
Other - Org Name:SHADY KNOLL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:41 SKOKORAT ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3826
Mailing Address - Country:US
Mailing Address - Phone:203-881-2555
Mailing Address - Fax:203-881-0853
Practice Address - Street 1:41 SKOKORAT ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-3826
Practice Address - Country:US
Practice Address - Phone:203-881-2555
Practice Address - Fax:203-881-0853
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA HEALTH CARE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2107C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000021702Medicaid
CT075386Medicare Oscar/Certification