Healthcare Provider Details

I. General information

NPI: 1033104856
Provider Name (Legal Business Name): MI NURSING-RESTORATIVE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 LAWRENCE ST
LAWRENCE MA
01841-3849
US

IV. Provider business mailing address

172 LAWRENCE ST
LAWRENCE MA
01841-3849
US

V. Phone/Fax

Practice location:
  • Phone: 978-685-6321
  • Fax: 978-975-0050
Mailing address:
  • Phone: 978-685-6321
  • Fax: 978-975-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number876
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7100450
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerEVERCARE
# 2
Identifier0998958
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MS. BARBARA E. GRANT
Title or Position: CEO/PRESIDENT
Credential:
Phone: 978-685-6321