Provider Demographics
NPI:1760628390
Name:COLONIAL CARE OF WINDHAM LLC
Entity Type:Organization
Organization Name:COLONIAL CARE OF WINDHAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RODOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-556-9177
Mailing Address - Street 1:595 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 VALLEY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1901
Practice Address - Country:US
Practice Address - Phone:760-423-2597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-03
Last Update Date:2009-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00002274314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075425Medicare PIN