Basic Information
| Provider Information | |||||||||
| NPI: | 1114594462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEASHORE POINTE REHAB CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 ALDEN ST | ||||||||
| Address2: | |||||||||
| City: | PROVINCETOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026571456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815880969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 ALDEN ST | ||||||||
| Address2: | |||||||||
| City: | PROVINCETOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026571456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084870771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | TSITOS | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7815880969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 110157998A | 05 | MA | MEDICAID |