MEDICARE: ISLAND TERRACE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	0614	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457346504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND TERRACE, INC.

Provider Business Mailing Address
First Line	:	57 LONG POINT RD
Second Line	:
City	:	LAKEVILLE
State	:	MA
Zip	:	02347-2124
Country	:	US
Telephone Number	:	508-947-0151
Fax Number	:	508-946-5335

Provider Business Practice Location Address
First Line	:	57 LONG POINT RD
Second Line	:
City	:	LAKEVILLE
State	:	MA
Zip	:	02347-2124
Country	:	US
Telephone Number	:	508-947-0151
Fax Number	:	508-946-5335

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BRENTON TOLLES
Credential	:	NHA
Telephone Number	:	508-947-0151

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	11/15/2007

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