Basic Information
| Provider Information | |||||||||
| NPI: | 1437146503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WORCESTER MA SNF LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WORCESTER REHABILITATION & HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 PROVIDENCE STREET | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088794050 | ||||||||
| FaxNumber: | 5088791534 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 PROVIDENCE STREET | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088605000 | ||||||||
| FaxNumber: | 5088605109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEMP | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5088794050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATHENA HEALTH CARE ASSOCIATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0726 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 110094544A | 05 | MA | MEDICAID |