Provider Demographics
NPI:1649487026
Name:MILL RIVER FOUNDATION, INC.
Entity type:Organization
Organization Name:MILL RIVER FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTLEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-619-0866
Mailing Address - Street 1:146 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3633
Mailing Address - Country:US
Mailing Address - Phone:203-964-8500
Mailing Address - Fax:203-356-9925
Practice Address - Street 1:146 W BROAD ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3633
Practice Address - Country:US
Practice Address - Phone:203-964-8500
Practice Address - Fax:203-356-9925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2327314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020313Medicaid
CT075360Medicare PIN