Healthcare Provider Details

I. General information

NPI: 1093184715
Provider Name (Legal Business Name): 279 CABOT STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 CABOT ST
HOLYOKE MA
01040-3139
US

IV. Provider business mailing address

279 CABOT ST
HOLYOKE MA
01040-3139
US

V. Phone/Fax

Practice location:
  • Phone: 413-536-3435
  • Fax: 413-536-3436
Mailing address:
  • Phone: 413-536-3435
  • Fax: 413-536-3436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742