1700872967 NPI number — ELLIS NURSING HOME, 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 1700872967 NPI number — ELLIS NURSING HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLIS NURSING HOME, 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:
ELLIS NURSING & REHABILITATION
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:
1700872967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 ELLIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWOOD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02062-3946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-762-6880
Provider Business Mailing Address Fax Number:
781-769-7515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 ELLIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWOOD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02062-3946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-762-6880
Provider Business Practice Location Address Fax Number:
781-769-7515
Provider Enumeration Date:
09/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCZEPANSKI
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
508-450-2482

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0793 , 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: 2222521101 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0908029 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 903249 . This is a "HARVARD PILGRIM HEALTH PL" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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