Healthcare Provider Details

I. General information

NPI: 1689140428
Provider Name (Legal Business Name): BEAR MT WEST ROXBURY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 WASHINGTON ST
WEST ROXBURY MA
02132-4738
US

IV. Provider business mailing address

130 S MAIN ST
THOMASTON CT
06787-1741
US

V. Phone/Fax

Practice location:
  • Phone: 617-323-5440
  • 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