Provider Demographics
NPI:1972633436
Name:THE MARY WADE HOME, INCORPORATED
Entity Type:Organization
Organization Name:THE MARY WADE HOME, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-672-7817
Mailing Address - Street 1:118 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3100
Mailing Address - Country:US
Mailing Address - Phone:203-562-7222
Mailing Address - Fax:203-848-6386
Practice Address - Street 1:118 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3100
Practice Address - Country:US
Practice Address - Phone:203-562-7222
Practice Address - Fax:203-848-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
CT261QR0400X
CT1665-RCH311ZA0620X
CT2051-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020511Medicaid