Provider Demographics
NPI:1609863737
Name:MATTATUCK HEALTH CARE FACILITY, INC.
Entity Type:Organization
Organization Name:MATTATUCK HEALTH CARE FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:DESENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-573-9924
Mailing Address - Street 1:9 CLIFF ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-2125
Mailing Address - Country:US
Mailing Address - Phone:203-573-9924
Mailing Address - Fax:203-573-0201
Practice Address - Street 1:9 CLIFF ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-2125
Practice Address - Country:US
Practice Address - Phone:203-573-9924
Practice Address - Fax:203-573-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT144-RH313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000091447Medicaid
CT075432Medicare ID - Type Unspecified