Provider Demographics
NPI:1104807304
Name:SPECTRUM HEALTHCARE WATERBRIDGE, LLC
Entity type:Organization
Organization Name:SPECTRUM HEALTHCARE WATERBRIDGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DICKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-871-5454
Mailing Address - Street 1:126 FORD ST
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2635
Mailing Address - Country:US
Mailing Address - Phone:860-871-5454
Mailing Address - Fax:860-871-5757
Practice Address - Street 1:126 FORD ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2635
Practice Address - Country:US
Practice Address - Phone:860-871-5454
Practice Address - Fax:860-871-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2261314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000021204Medicaid
CT075392Medicare Oscar/Certification