=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043401136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNS REST HOME INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 08/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 BOWDOIN AVE
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-825-1793
-----------------------------------------------------
Fax | 617-825-1793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 BOWDOIN AVE
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-825-1793
-----------------------------------------------------
Fax | 617-825-1793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. WILLARD L BASLER
-----------------------------------------------------
Credential | PRESIDENT
-----------------------------------------------------
Telephone | 617-825-1793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 2560
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------