Healthcare Provider Details

I. General information

NPI: 1073562021
Provider Name (Legal Business Name): WINGATE AT ANDOVER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 ANDOVER ST
ANDOVER MA
01810-5606
US

IV. Provider business mailing address

63 KENDRICK ST
NEEDHAM MA
02494-2708
US

V. Phone/Fax

Practice location:
  • Phone: 978-470-3434
  • Fax: 978-475-7097
Mailing address:
  • Phone: 781-707-9085
  • Fax: 781-707-9285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0937
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110026360B
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MS. TAMILYN M. LEVIN
Title or Position: CFO
Credential: ESQ.
Phone: 781-707-9510