Basic Information
| Provider Information | |||||||||
| NPI: | 1396109195 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANE COLONIAL, LLC | ||||||||
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| OtherOrganizationName: | COLONIAL 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: | 7818713986 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021882336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813373121 | ||||||||
| FaxNumber: | 7813379831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2016 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | BANE | ||||||||
| AuthorizedOfficialFirstName: | HARRISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7818786700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
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 | 70012222205201 | 01 | MA | BLUE CROSS | OTHER | 110117821A | 05 | MA | MEDICAID |