Healthcare Provider Details

I. General information

NPI: 1639286750
Provider Name (Legal Business Name): AVERY MANOR NURSING, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST ST
NEEDHAM MA
02494-1319
US

IV. Provider business mailing address

680 S 4TH ST
LOUISVILLE KY
40202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 781-234-6300
  • Fax: 781-234-6832
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier0927961
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier907779
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerEVERCARE
# 3
Identifier000000023951
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBMC HEALTH NET
# 4
Identifier2222567401
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS BLUE SHIELD
# 5
Identifier637422
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMULTIPLAN
# 6
Identifier0020004
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMARTINS POINT
# 7
Identifier0926272
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMVP
# 8
Identifier71-00783
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerCIGNA

VIII. Authorized Official

Name: MS. MARILYN WEAVER
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 502-596-7563