Provider Demographics
NPI:1760633366
Name:915 ELLA T GRASSO BOULEVARD OPERATIONS LLC
Entity Type:Organization
Organization Name:915 ELLA T GRASSO BOULEVARD OPERATIONS LLC
Other - Org Name:UNIVERSITY SKILLED NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-925-4045
Mailing Address - Street 1:915 ELLA T GRASSO BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-5516
Mailing Address - Country:US
Mailing Address - Phone:203-865-5155
Mailing Address - Fax:203-865-5799
Practice Address - Street 1:915 ELLA T GRASSO BLVD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-5516
Practice Address - Country:US
Practice Address - Phone:203-865-5155
Practice Address - Fax:203-865-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2254314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020496Medicaid
CT075179001Medicare Oscar/Certification