MEDICARE: 19 VARNUM STREET OPERATING CO,LLC

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		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	:	1538159785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	19 VARNUM STREET OPERATING CO,LLC

Provider Business Mailing Address
First Line	:	19 VARNUM ST
Second Line	:
City	:	LOWELL
State	:	MA
Zip	:	01850-2132
Country	:	US
Telephone Number	:	978-454-5644
Fax Number	:	978-459-7367

Provider Business Practice Location Address
First Line	:	19 VARNUM ST
Second Line	:
City	:	LOWELL
State	:	MA
Zip	:	01850-2132
Country	:	US
Telephone Number	:	978-454-5644
Fax Number	:	978-459-7367

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MARK O'FLAHERTY
Credential	:
Telephone Number	:	978-454-5644

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	08/22/2020

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