Provider Demographics
NPI:1679603732
Name:MARY ELIZABETH NURSING CENTER INC.
Entity Type:Organization
Organization Name:MARY ELIZABETH NURSING CENTER 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 1:28 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2833
Mailing Address - Country:US
Mailing Address - Phone:860-536-9655
Mailing Address - Fax:860-536-4571
Practice Address - Street 1:28 BROADWAY
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2833
Practice Address - Country:US
Practice Address - Phone:860-536-9655
Practice Address - Fax:860-536-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1068-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000010637Medicaid
CT075327Medicare Oscar/Certification