Healthcare Provider Details

I. General information

NPI: 1609905512
Provider Name (Legal Business Name): LARCHWOOD LODGE NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BACON ST 325 BACON STREET
WALTHAM MA
02451-7519
US

IV. Provider business mailing address

96 HILLSIDE AVE 96 HILLSIDE AVE
NEEDHAM MA
02494-1710
US

V. Phone/Fax

Practice location:
  • Phone: 781-894-5264
  • Fax: 781-894-6011
Mailing address:
  • Phone: 781-894-5264
  • Fax: 781-894-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0214
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier0921947
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MRS. JAN GALATIS
Title or Position: OWNER
Credential:
Phone: 781-894-5264