1104940287 NPI number — PARK AVENUE NURSING & REHABILITATION CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104940287 NPI number — PARK AVENUE NURSING & REHABILITATION CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK AVENUE NURSING & REHABILITATION CENTER INC
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:
PARK AVENUE NURSING & REHABILITATION CENTER
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:
1104940287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
146 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02476-5829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-648-9530
Provider Business Mailing Address Fax Number:
781-646-3668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
146 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02476-5829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-648-9530
Provider Business Practice Location Address Fax Number:
781-646-3668
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALESSANDRONI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
781-648-9530

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0777 , 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: 7100196 . This is a "EVERCARE PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0904988 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 906183 . This is a "HARVARD PILGRIM PROVID #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 904423 . This is a "TUFTS HEALTH PLAN PROV #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2222558401 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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