Healthcare Provider Details

I. General information

NPI: 1992784037
Provider Name (Legal Business Name): AGAWAM NURSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SUFFIELD ST
AGAWAM MA
01001-2933
US

IV. Provider business mailing address

50 KERRY PL
NORWOOD MA
02062-4775
US

V. Phone/Fax

Practice location:
  • Phone: 413-789-2200
  • Fax:
Mailing address:
  • Phone: 781-619-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0967
License Number StateMA

VIII. Authorized Official

Name: MR. BRAD ROLPH
Title or Position: CFO
Credential:
Phone: 781-297-8626