=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871540070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLLYWELL HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 N MAIN ST
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02368-3056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-963-8800
-----------------------------------------------------
Fax | 781-963-8922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 N MAIN ST
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02368-3056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-963-8800
-----------------------------------------------------
Fax | 781-963-8922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTH. PERSON/ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOSEPH VENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-963-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0439
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------