Basic Information
| Provider Information | |||||||||
| NPI: | 1730176561 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEASHORE POINT-DEACONESS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEASHORE POINT WELLNESS & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 DEACONESS ROAD | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783695151 | ||||||||
| FaxNumber: | 9783711755 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 ALDEN ST | ||||||||
| Address2: | |||||||||
| City: | PROVINCETOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084877090 | ||||||||
| FaxNumber: | 5084872967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | HERB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9783695151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEASHORE POINT-DEACONESS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0849 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0940003 | 05 | MA | MEDICAID |