Healthcare Provider Details

I. General information

NPI: 1285184085
Provider Name (Legal Business Name): WV-CONCORD SNF OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 MAIN ST
CONCORD MA
01742-3310
US

IV. Provider business mailing address

36 WASHINGTON ST SUITE 190
WELLESLEY HILLS MA
02481-1900
US

V. Phone/Fax

Practice location:
  • Phone: 978-369-6889
  • Fax:
Mailing address:
  • Phone: 781-943-3104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier110100396A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MR. RAYMOND A. DENNEHY III
Title or Position: PRINCIPAL
Credential:
Phone: 978-886-3336