Basic Information
| Provider Information | |||||||||
| NPI: | 1497748735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROAD REACH OF CHATHAM INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LIBERTY COMMONS NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 ORLEANS RD | ||||||||
| Address2: | |||||||||
| City: | N CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026501154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089454611 | ||||||||
| FaxNumber: | 5089452245 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 ORLEANS RD | ||||||||
| Address2: | |||||||||
| City: | N CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026501154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089454611 | ||||||||
| FaxNumber: | 5089452245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOGDANOVICH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5089454611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0884 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0922935 | 05 | MA | MEDICAID |