MEDICARE: ELIZABETH CATHERINE REST HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1417529066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIZABETH CATHERINE REST HOME LLC

Provider Business Mailing Address
First Line	:	38 WELCH RD
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02445-7526
Country	:	US
Telephone Number	:	617-751-0444
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 FRONT ST
Second Line	:
City	:	WEYMOUTH
State	:	MA
Zip	:	02188-1604
Country	:	US
Telephone Number	:	781-337-0772
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/MEMBER
Name	:	MR. IRSHAD SIDEEKA
Credential	:
Telephone Number	:	617-751-0444

Provider Enumeration Date	:	07/13/2021
Last Update Date	:	07/13/2021

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