Provider Demographics
NPI:1427250885
Name:MASONICARE HEALTH CENTER
Entity type:Organization
Organization Name:MASONICARE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON-PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VENOIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-679-5000
Mailing Address - Street 1:22 MASONIC AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3048
Mailing Address - Country:US
Mailing Address - Phone:203-679-5900
Mailing Address - Fax:
Practice Address - Street 1:22 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3048
Practice Address - Country:US
Practice Address - Phone:203-679-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0075335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004014791Medicaid