Provider Demographics
NPI:1730137993
Name:WADSWORTH GLEN INC
Entity Type:Organization
Organization Name:WADSWORTH GLEN INC
Other - Org Name:WADSWORTH GLEN HEALTH CARE & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANTILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:30 BOSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-346-9299
Mailing Address - Fax:860-343-5030
Practice Address - Street 1:30 BOSTON ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-346-9299
Practice Address - Fax:860-343-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2025C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020256Medicaid
075312Medicare ID - Type Unspecified