Provider Demographics
NPI:1457502924
Name:97 PRESTON ROAD OPERATIONS LLC
Entity Type:Organization
Organization Name:97 PRESTON ROAD OPERATIONS LLC
Other - Org Name:GRISWOLD SKILLED NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-925-4045
Mailing Address - Street 1:97 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2516
Mailing Address - Country:US
Mailing Address - Phone:860-376-4438
Mailing Address - Fax:860-376-8343
Practice Address - Street 1:97 PRESTON RD
Practice Address - Street 2:
Practice Address - City:GRISWOLD
Practice Address - State:CT
Practice Address - Zip Code:06351-2516
Practice Address - Country:US
Practice Address - Phone:860-376-4438
Practice Address - Fax:860-376-8343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2256314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility