Provider Demographics
NPI:1437175932
Name:LEDGECREST HEALTH CARE CENTER INC.
Entity Type:Organization
Organization Name:LEDGECREST HEALTH CARE CENTER INC.
Other - Org Name:LEDGECREST HEALTH CARE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-678-9755
Mailing Address - Street 1:154 KENSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2602
Mailing Address - Country:US
Mailing Address - Phone:860-828-0583
Mailing Address - Fax:860-828-4946
Practice Address - Street 1:154 KENSINGTON RD
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-2602
Practice Address - Country:US
Practice Address - Phone:860-828-0583
Practice Address - Fax:860-828-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2046C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020462Medicaid
CT808OtherBC
CT808OtherBC