Healthcare Provider Details

I. General information

NPI: 1982179610
Provider Name (Legal Business Name): BEAR MT MATTAPAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 RIVER ST
MATTAPAN MA
02126-2210
US

IV. Provider business mailing address

13 S MAIN ST
THOMASTON CT
06787-1735
US

V. Phone/Fax

Practice location:
  • Phone: 617-296-5585
  • Fax:
Mailing address:
  • Phone: 203-904-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. JOHN WYNNE
Title or Position: CFO
Credential:
Phone: 203-904-7462