Provider Demographics
NPI:1992793491
Name:ST. JOHNSBURY HEALTH AND REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:ST. JOHNSBURY HEALTH AND REHABILITATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LLC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCILLIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-608-6100
Mailing Address - Street 1:538 PRESTON AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4851
Mailing Address - Country:US
Mailing Address - Phone:203-608-6100
Mailing Address - Fax:203-639-3574
Practice Address - Street 1:1248 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9239
Practice Address - Country:US
Practice Address - Phone:802-748-8757
Practice Address - Fax:802-748-6503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERMONT SUBACUTE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-10
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0270000333314000000X
VT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0475019Medicaid
475019BMedicare Oscar/Certification
VT475019BMedicare Oscar/Certification