Basic Information
Provider Information | |||||||||
NPI: | 1912962796 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SNH SE TENANT TRS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHURCH CREEK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 WASHINGTON STREET | ||||||||
Address2: | 2 NEWTON PLACE | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038540823 | ||||||||
FaxNumber: | 7038540164 | ||||||||
Practice Location | |||||||||
Address1: | 1200 W CENTRAL RD | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600052403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475063200 | ||||||||
FaxNumber: | 8475062598 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2006 | ||||||||
LastUpdateDate: | 10/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINTZER | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6177968350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SNH SE TENANT TRS, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X |   |   | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 314000000X | 0043893 | IL | N |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.