Basic Information
| Provider Information | |||||||||
| NPI: | 1366858201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLYMOUTH MA SNF, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLYMOUTH REHAB & HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087464343 | ||||||||
| FaxNumber: | 5087468240 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087464343 | ||||||||
| FaxNumber: | 5087468240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | SANTILLI | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8607513900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATHENA HEALTH CARE ASSOCIATES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | 0734 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 110094527D | 05 | MA | MEDICAID |