Provider Demographics
NPI:1922031228
Name:HARBORSIDE CONNECTICUT LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:HARBORSIDE CONNECTICUT LIMITED PARTNERSHIP
Other - Org Name:WILLOWS CARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:225 AMITY RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2206
Practice Address - Country:US
Practice Address - Phone:203-387-0076
Practice Address - Fax:203-397-3653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2202-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT20553Medicaid
075331Medicare Oscar/Certification