Healthcare Provider Details

I. General information

NPI: 1700884582
Provider Name (Legal Business Name): 2101 WASHINGTON STREET OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 WASHINGTON STREET
NEWTON MA
02462
US

IV. Provider business mailing address

2101 WASHINGTON STREET
NEWTON MA
02462
US

V. Phone/Fax

Practice location:
  • Phone: 617-969-4660
  • Fax: 617-964-4622
Mailing address:
  • Phone: 617-969-4660
  • Fax: 617-964-4622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0736
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier0926906
Identifier TypeMEDICAID
Identifier StateDE
Identifier Issuer

VIII. Authorized Official

Name: EMILY VAZQUEZ
Title or Position: VP, SPECIAL PROJECTS
Credential:
Phone: 978-930-6051