Basic Information
Provider Information | |||||||||
NPI: | 1548250079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLYMOUTH MA SNF LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PLYMOUTH REHABILITATION & HEALTH CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 123 SOUTH STREET | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 02360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088794050 | ||||||||
FaxNumber: | 5088791534 | ||||||||
Practice Location | |||||||||
Address1: | 123 SOUTH STREET | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 02360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087464343 | ||||||||
FaxNumber: | 5087468240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2005 | ||||||||
LastUpdateDate: | 12/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0734 | MA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 110094527C | 05 | MA |   | MEDICAID |