Basic Information
| Provider Information | |||||||||
| NPI: | 1417347170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST REVERE HEALTH CENTER, LLC | ||||||||
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| OtherOrganizationName: | WEST REVERE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2363 LAKEWOOD RD | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087551524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327104431 | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021511114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813224861 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 02/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | FISCH | ||||||||
| AuthorizedOfficialFirstName: | ELI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF VENDOR RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7327104431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
No ID Information.