Basic Information
| Provider Information | |||||||||
| NPI: | 1205818333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANNEMARK NURSING HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021511114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813224861 | ||||||||
| FaxNumber: | 7813241191 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021511114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813224861 | ||||||||
| FaxNumber: | 7813241191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEAN | ||||||||
| AuthorizedOfficialFirstName: | ELENA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7813224861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0864 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0914525 | 05 | MA | MEDICAID | 225432 | 01 | MA | MEDEX | OTHER | 225432 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 670680 | 01 | MA | TUFTS PROVIDER NUMBER | OTHER |