Healthcare Provider Details

I. General information

NPI: 1609733757
Provider Name (Legal Business Name): 405 RIVER STREET OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 RIVER ST
MATTAPAN MA
02126-2210
US

IV. Provider business mailing address

405 RIVER ST
MATTAPAN MA
02126-2210
US

V. Phone/Fax

Practice location:
  • Phone: 617-296-5585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: JEFFREY RUBIN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 516-413-6321