Provider Demographics
NPI:1780635938
Name:MYSTIC HEALTHCARE & REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:MYSTIC HEALTHCARE & REHABILITATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SBRIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-381-1327
Mailing Address - Street 1:475 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-536-6070
Mailing Address - Fax:860-536-9480
Practice Address - Street 1:475 HIGH STREET
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-536-6070
Practice Address - Fax:860-536-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT839-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000008391Medicaid
CT075271Medicare Oscar/Certification