1720496318 NPI number — PEREGRINE SENIOR LIVING OF TEWKSBURY, LLC

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 1720496318 NPI number — PEREGRINE SENIOR LIVING OF TEWKSBURY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEREGRINE SENIOR LIVING OF TEWKSBURY, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1720496318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 MONTGOMERY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13202-1937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-476-5610
Provider Business Mailing Address Fax Number:
315-475-8729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 MAIN ST # 2850
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEWKSBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01876-4737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-377-1622
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
315-476-5610

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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