Provider Demographics
NPI:1588650840
Name:GREENTREE MANOR NURSING AND REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:GREENTREE MANOR NURSING AND REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOPCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-442-0647
Mailing Address - Street 1:4 GREENTREE DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4116
Mailing Address - Country:US
Mailing Address - Phone:860-442-0647
Mailing Address - Fax:860-439-0821
Practice Address - Street 1:4 GREENTREE DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4116
Practice Address - Country:US
Practice Address - Phone:860-442-0647
Practice Address - Fax:860-439-0821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RYDERS HEALTH MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-22
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2206C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000008425Medicaid
075113Medicare UPIN