Provider Demographics
NPI:1598833725
Name:ORCHARD GROVE SPECIALTY CARE CENTER
Entity Type:Organization
Organization Name:ORCHARD GROVE SPECIALTY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-678-9755
Mailing Address - Street 1:5 RICHARD BROWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382
Mailing Address - Country:US
Mailing Address - Phone:860-848-8466
Mailing Address - Fax:860-848-7456
Practice Address - Street 1:5 RICHARD BROWN DRIVE
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382
Practice Address - Country:US
Practice Address - Phone:860-848-8466
Practice Address - Fax:860-848-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2306-C313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0095241Medicaid