Provider Demographics
NPI:1245228444
Name:REVERA (DELAWARE) LLC
Entity Type:Organization
Organization Name:REVERA (DELAWARE) LLC
Other - Org Name:MONTESANO HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LLC 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:
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 1:800 N. MEDCALF
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-1318
Practice Address - Country:US
Practice Address - Phone:360-249-2273
Practice Address - Fax:360-249-2363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA050005680314000000X
WA1369314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113692Medicaid
WA505503Medicare Oscar/Certification
WA4113692Medicaid