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General NPI Number Information
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NPI Number | 1104017292
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Entity Type | Organization
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Legal Business Name | BURGOYNE REST HOME INC
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 08/05/2007
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Provider Practice Location Address
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Address Line | 53 HARTFORD ST
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City | DORCHESTER
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State | MA
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Zip | 02125-2829
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Country | US
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Telephone | 617-445-1868
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Fax | 617-445-2066
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Provider Business Mailing Address
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Address Line | 53 HARTFORD ST
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City | DORCHESTER
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State | MA
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Zip | 02125-2829
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Country | US
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Telephone | 617-445-1868
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Fax | 617-445-2066
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. WILLARD L L BASLER
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Credential | ADM
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Telephone | 617-445-1868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 1027
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License Number State | MA
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