Healthcare Provider Details

I. General information

NPI: 1396109195
Provider Name (Legal Business Name): BANE COLONIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BROAD ST
WEYMOUTH MA
02188-2336
US

IV. Provider business mailing address

350 GRANITE ST STE 2203
BRAINTREE MA
02184-4963
US

V. Phone/Fax

Practice location:
  • Phone: 781-337-3121
  • Fax: 781-337-9831
Mailing address:
  • Phone: 781-474-2263
  • Fax: 781-871-3986

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: MR. HARRISON BANE
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 781-878-6700