Provider Demographics
NPI:1558430256
Name:WATERBURY EXTENDED CARE FACILITY, INC.
Entity Type:Organization
Organization Name:WATERBURY EXTENDED CARE FACILITY, INC.
Other - Org Name:
Other - Org Type:
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 1:35 BUNKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-3304
Mailing Address - Country:US
Mailing Address - Phone:860-274-5428
Mailing Address - Fax:860-945-7034
Practice Address - Street 1:35 BUNKER HILL RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3304
Practice Address - Country:US
Practice Address - Phone:860-274-5428
Practice Address - Fax:860-945-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1082-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000010827Medicaid
CT075181Medicare Oscar/Certification