Provider Demographics
NPI:1497054316
Name:EASTER SEAL REHABILITATION CENTER
Entity Type:Organization
Organization Name:EASTER SEAL REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-754-5141
Mailing Address - Street 1:22 TOMPKINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1496
Mailing Address - Country:US
Mailing Address - Phone:203-754-5141
Mailing Address - Fax:203-757-1198
Practice Address - Street 1:22 TOMPKINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1496
Practice Address - Country:US
Practice Address - Phone:203-754-5141
Practice Address - Fax:203-757-1198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12DME0601CT01OtherANTHEM BLUE CROSS BLUE SHIELD
232000OtherCONNECTICARE
CT017500OtherCONNECTICARE
5376280OtherAETNA
CT5617574OtherAETNA
CT800009105CT01OtherANTHEM BLUE CROSS BLUE SHIELD