Provider Demographics
NPI:1275609398
Name:CLINTONVILLE MANOR
Entity Type:Organization
Organization Name:CLINTONVILLE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIMONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-239-8017
Mailing Address - Street 1:201 CLINTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2409
Mailing Address - Country:US
Mailing Address - Phone:203-239-8017
Mailing Address - Fax:203-234-0758
Practice Address - Street 1:201 CLINTONVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2409
Practice Address - Country:US
Practice Address - Phone:203-239-8017
Practice Address - Fax:203-234-0758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT183-RH313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075433Medicare Oscar/Certification