Basic Information
| Provider Information | |||||||||
| NPI: | 1588732697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOLAMOR HOSPICE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SOLAMOR HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MIDSTATE DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | AUBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015011856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088452379 | ||||||||
| FaxNumber: | 5088459670 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 MIDSTATE DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | AUBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015011856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088452379 | ||||||||
| FaxNumber: | 5088459670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAVALLO | ||||||||
| AuthorizedOfficialFirstName: | GLEN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4799965900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOLAMOR HOSPICE CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | MA | N | Agencies | Hospice Care, Community Based | 251G00000X | 7PKE | MA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0608467 | 05 | MA | MEDICAID | 110073024B | 05 | MA | MEDICAID |