Healthcare Provider Details

I. General information

NPI: 1104044981
Provider Name (Legal Business Name): VILLAGE REST HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 W CHESTNUT ST
BROCKTON MA
02301-6753
US

IV. Provider business mailing address

30 SINCLAIR RD
BROCKTON MA
02302-4452
US

V. Phone/Fax

Practice location:
  • Phone: 508-583-0040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: GUY MARCELLUS
Title or Position: DIRECTOR
Credential:
Phone: 508-583-0040