Healthcare Provider Details

I. General information

NPI: 1639615099
Provider Name (Legal Business Name): 2000 EMERALD COURT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 EMERALD CT
TEWKSBURY MA
01876-5220
US

IV. Provider business mailing address

2000 EMERALD CT
TEWKSBURY MA
01876-5220
US

V. Phone/Fax

Practice location:
  • Phone: 978-640-0194
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateMA

VIII. Authorized Official

Name: SHAWN BERTRAM
Title or Position: VP OF OPERATIONS
Credential:
Phone: 508-404-3534