Basic Information
| Provider Information | |||||||||
| NPI: | 1881682854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHBRIDGE MA SNF LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84 CHAPIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015502408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088794050 | ||||||||
| FaxNumber: | 5088791534 | ||||||||
| Practice Location | |||||||||
| Address1: | 84 CHAPIN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015502408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088794050 | ||||||||
| FaxNumber: | 5088791534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOSIER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8607513900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATHENA HEALTH CARE ASSOCIATES, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0820 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 110094538A | 05 | MA | MEDICAID |