Healthcare Provider Details

I. General information

NPI: 1306311030
Provider Name (Legal Business Name): BEAR MT PARKWAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 VFW PKWY
WEST ROXBURY MA
02132-4208
US

IV. Provider business mailing address

130 S MAIN ST
THOMASTON CT
06787-1741
US

V. Phone/Fax

Practice location:
  • Phone: 617-325-1688
  • Fax:
Mailing address:
  • Phone: 203-904-7462
  • 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
Title or Position: CFO
Credential:
Phone: 203-904-7462