Healthcare Provider Details

I. General information

NPI: 1184207557
Provider Name (Legal Business Name): BEAR MT NORTH ANDOVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PRESCOTT ST
NORTH ANDOVER MA
01845-1826
US

IV. Provider business mailing address

130 S MAIN ST STE 207
THOMASTON CT
06787-1741
US

V. Phone/Fax

Practice location:
  • Phone: 978-685-8086
  • Fax:
Mailing address:
  • Phone: 860-880-8202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN WYNNE JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 860-880-8202