Healthcare Provider Details

I. General information

NPI: 1144223074
Provider Name (Legal Business Name): MEDWAY COUNTRY MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HOLLISTON ST
MEDWAY MA
02053-1954
US

IV. Provider business mailing address

115 HOLLISTON ST
MEDWAY MA
02053-1954
US

V. Phone/Fax

Practice location:
  • Phone: 508-533-6634
  • Fax: 508-533-7048
Mailing address:
  • Phone: 508-533-6634
  • Fax: 508-533-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0840
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0840
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0840
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0840
License Number StateMA

VIII. Authorized Official

Name: MR. DAVID SIMHA
Title or Position: PRESIDENT
Credential:
Phone: 917-885-7050