1831173400 NPI number — CLINTON MANOR NURSING HOME

Table of content: (NPI 1831173400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831173400 NPI number — CLINTON MANOR NURSING HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON MANOR NURSING HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STERLING HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831173400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 DANA HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01564-2414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-422-5111
Provider Business Mailing Address Fax Number:
978-422-5925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 DANA HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01564-2414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-422-5111
Provider Business Practice Location Address Fax Number:
978-422-5925
Provider Enumeration Date:
12/06/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUBY
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
978-422-5111

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0082 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 696132 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2222545201 . This is a "BC BS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0913367 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".