=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730300294
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR LADY OF MERCY HEALTH CARE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 BARRY RD
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-798-3727
-----------------------------------------------------
Fax | 508-757-9415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 BARRY RD
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-798-3727
-----------------------------------------------------
Fax | 508-757-9415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANNA MARIE TAG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-798-3727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 1T61
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------