Basic Information
| Provider Information | |||||||||
| NPI: | 1629108055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINDA MANOR NURSING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LINDA MANOR EXTENDED CARE FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 349 HAYDENVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEEDS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010539767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135867700 | ||||||||
| FaxNumber: | 4135868137 | ||||||||
| Practice Location | |||||||||
| Address1: | 349 HAYDENVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEEDS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010539767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135867700 | ||||||||
| FaxNumber: | 4135868137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEARY | ||||||||
| AuthorizedOfficialFirstName: | AMALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4134472416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0907 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0928941 | 05 | MA | MEDICAID |