Healthcare Provider Details

I. General information

NPI: 1881123263
Provider Name (Legal Business Name): 1199 JOHN FITCH HIGHWAY OPERATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 JOHN FITCH HWY
FITCHBURG MA
01420-2026
US

IV. Provider business mailing address

75 2ND AVE STE 605
NEEDHAM MA
02494-2863
US

V. Phone/Fax

Practice location:
  • Phone: 978-345-0146
  • Fax: 978-345-4053
Mailing address:
  • Phone: 617-943-7747
  • Fax: 617-454-1051

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: WILLIAM HOWARD STEPHAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 617-943-7747