Healthcare Provider Details

I. General information

NPI: 1205854981
Provider Name (Legal Business Name): MEDWAY COUNTRY MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/30/2007
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: 508-533-9893
  • Fax: 508-533-7048
Mailing address:
  • Phone: 508-533-9893
  • Fax: 508-533-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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

VIII. Authorized Official

Name: MR. JOHN PETERS III
Title or Position: TREASURER
Credential:
Phone: 508-533-6634