Basic Information
| Provider Information | |||||||||
| NPI: | 1972582013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEDHAM NURSING LLC | ||||||||
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| OtherOrganizationName: | HIGHGATE MANOR CENTER FOR HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 KERRY PL | ||||||||
| Address2: | |||||||||
| City: | NORWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020624775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816190250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 CAREMATRIX DR | ||||||||
| Address2: | |||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020266149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814619663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROLPH | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7812978626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | OMWV | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0926264 | 05 | MA | MEDICAID |