Provider Demographics
NPI:1417942491
Name:WOLCOTT VIEW MANOR, INC.
Entity Type:Organization
Organization Name:WOLCOTT VIEW MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLEARY, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-879-8066
Mailing Address - Street 1:50 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-1902
Mailing Address - Country:US
Mailing Address - Phone:203-879-8066
Mailing Address - Fax:203-879-8072
Practice Address - Street 1:50 BEACH RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1902
Practice Address - Country:US
Practice Address - Phone:203-879-8066
Practice Address - Fax:203-879-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT972-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000009720Medicaid
CT0733600001Medicare NSC
CT000009720Medicaid