Healthcare Provider Details

I. General information

NPI: 1902817299
Provider Name (Legal Business Name): 184 MAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 MAIN STREET
FAIRHAVEN MA
02719
US

IV. Provider business mailing address

184 MAIN STREET
FAIRHAVEN MA
02719
US

V. Phone/Fax

Practice location:
  • Phone: 508-997-3193
  • Fax: 508-991-5615
Mailing address:
  • Phone: 508-997-3193
  • Fax: 508-991-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0646
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: PAULA REID
Title or Position: CONTROLLER
Credential:
Phone: 508-743-8159