Healthcare Provider Details

I. General information

NPI: 1467912105
Provider Name (Legal Business Name): BEAR MT EAST LONGMEADOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 CHESTNUT ST
EAST LONGMEADOW MA
01028-2803
US

IV. Provider business mailing address

130 S MAIN ST STE 203
THOMASTON CT
06787-1741
US

V. Phone/Fax

Practice location:
  • Phone: 413-525-1893
  • Fax:
Mailing address:
  • Phone: 860-880-8202
  • Fax: 860-880-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN WYNNE JR.
Title or Position: MEMBER/CFO
Credential:
Phone: 860-880-8202