Provider Demographics
NPI:1609241660
Name:SMITH HOUSE OPERATING, LLC
Entity Type:Organization
Organization Name:SMITH HOUSE OPERATING, LLC
Other - Org Name:THE VILLA AT STAMFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES-EDOUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-360-8083
Mailing Address - Street 1:460 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-1702
Mailing Address - Country:US
Mailing Address - Phone:718-360-8083
Mailing Address - Fax:
Practice Address - Street 1:88 ROCK RIMMON RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-2817
Practice Address - Country:US
Practice Address - Phone:718-360-8083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMITH HOUSE VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT716-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000007161Medicaid
075153Medicare PIN