Healthcare Provider Details

I. General information

NPI: 1972977593
Provider Name (Legal Business Name): SRC BREWSTER SNF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 HARWICH RD
BREWSTER MA
02631-5232
US

IV. Provider business mailing address

63 KENDRICK ST
NEEDHAM MA
02494-2708
US

V. Phone/Fax

Practice location:
  • Phone: 508-896-7046
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TAMILYN LEVIN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 781-707-9510