Provider Demographics
NPI:1912952359
Name:MARATHON HEALTHCARE CENTER OF WATERBURY LLC
Entity Type:Organization
Organization Name:MARATHON HEALTHCARE CENTER OF WATERBURY LLC
Other - Org Name:MARATHON HEALTHCARE CENTER OF WATERBURY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RECEIVER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BELMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-644-6780
Mailing Address - Street 1:99 EAST RIVER DR.
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3288
Mailing Address - Country:US
Mailing Address - Phone:860-289-8762
Mailing Address - Fax:860-528-5711
Practice Address - Street 1:177 WHITEWOOD RD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1545
Practice Address - Country:US
Practice Address - Phone:203-757-9491
Practice Address - Fax:203-757-4329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2326314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000009001Medicaid
NY00312170Medicaid
CT075219Medicare ID - Type Unspecified