Provider Demographics
NPI:1275918443
Name:55 KONDRACKI LANE OPERATIONS LLC
Entity Type:Organization
Organization Name:55 KONDRACKI LANE OPERATIONS LLC
Other - Org Name:QUINNIPIAC VALLEY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:55 KONDRACKI LN
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4951
Mailing Address - Country:US
Mailing Address - Phone:203-265-6771
Mailing Address - Fax:203-265-6772
Practice Address - Street 1:55 KONDRACKI LN
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4951
Practice Address - Country:US
Practice Address - Phone:203-265-6771
Practice Address - Fax:203-265-6772
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility