Healthcare Provider Details

I. General information

NPI: 1407859564
Provider Name (Legal Business Name): SOUTH COVE MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SHAWMUT AVENUE
BOSTON MA
02118-2293
US

IV. Provider business mailing address

120 SHAWMUT AVENUE
BOSTON MA
02118-2293
US

V. Phone/Fax

Practice location:
  • Phone: 617-423-0590
  • Fax: 617-292-7922
Mailing address:
  • Phone: 617-423-0590
  • Fax: 617-292-7922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0876
License Number StateMA

VIII. Authorized Official

Name: MR. RICHARD WONG
Title or Position: PRESIDENT / CEO
Credential:
Phone: 617-423-0590