Healthcare Provider Details

I. General information

NPI: 1215924303
Provider Name (Legal Business Name): PARK PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CENTRAL AVE
HYDE PARK MA
02136-3021
US

IV. Provider business mailing address

113 CENTRAL AVE
HYDE PARK MA
02136-3021
US

V. Phone/Fax

Practice location:
  • Phone: 617-361-2388
  • Fax: 617-364-3112
Mailing address:
  • Phone: 617-361-2388
  • Fax: 617-364-3112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0500
License Number StateMA

VIII. Authorized Official

Name: MS. LAURA MCDONNELL
Title or Position: CORPORATE BUSINESS OFFICE MANAGER
Credential:
Phone: 978-420-1500