Basic Information
| Provider Information | |||||||||
| NPI: | 1174978100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANE HARBOR HOUSE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARBOR HOUSE REHABILITATION AND NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 GRANITE ST STE 2203 | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021844963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814742263 | ||||||||
| FaxNumber: | 7818789807 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 CONDITO RD | ||||||||
| Address2: | |||||||||
| City: | HINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020431746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817494774 | ||||||||
| FaxNumber: | 7817496881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | BANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7814742263 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 70012222205301 | 01 | MA | BLUE CROSS | OTHER | 110116523A | 05 | MA | MEDICAID |