Provider Demographics
NPI:1376543751
Name:LUTHERAN HOME OF SOUTHBURY INC
Entity Type:Organization
Organization Name:LUTHERAN HOME OF SOUTHBURY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-264-9135
Mailing Address - Street 1:990 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-1267
Mailing Address - Country:US
Mailing Address - Phone:203-264-9135
Mailing Address - Fax:203-262-6714
Practice Address - Street 1:990 MAIN ST N
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-1267
Practice Address - Country:US
Practice Address - Phone:203-264-9135
Practice Address - Fax:203-262-6714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT699C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075371Medicare ID - Type Unspecified