Basic Information
| Provider Information | |||||||||
| NPI: | 1760426282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWOOD MA SNF LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWOOD REHABILITATION & HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018541915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088794050 | ||||||||
| FaxNumber: | 5088791534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 VARNUM AVENUE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784588773 | ||||||||
| FaxNumber: | 9784586366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | KEMP | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5088794050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATHENA HEALTH CARE ASSOCIATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0838 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 249 | 01 | MA | FALLON VENDOR CODE | OTHER | 2222529801 | 01 | MA | BC/BS OF MA PROVIDER NUMB | OTHER | 907339 | 01 | MA | HARVARD PILGRIM PROV NUMB | OTHER | 914985 | 01 | MA | TUFTS MEDICARE PREFERRED | OTHER | 110094540A | 05 | MA | MEDICAID | 7100155 | 01 | MA | EVERCARE PROV # | OTHER |