Provider Demographics
NPI:1730451501
Name:WADSWORTH GLEN, INC
Entity type:Organization
Organization Name:WADSWORTH GLEN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:30 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3543
Mailing Address - Country:US
Mailing Address - Phone:860-346-9299
Mailing Address - Fax:860-343-5030
Practice Address - Street 1:30 BOSTON RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3543
Practice Address - Country:US
Practice Address - Phone:860-346-9299
Practice Address - Fax:860-343-5030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA HEALTH CARE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-08
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2025C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000020256Medicaid
CT075312Medicare Oscar/Certification