MEDICARE: WELL LCB PORTFOLIO 1 TENANT, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1700416526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL LCB PORTFOLIO 1 TENANT, LLC

Provider Business Mailing Address
First Line	:	3 EDGEWATER DR STE 101
Second Line	:
City	:	NORWOOD
State	:	MA
Zip	:	02062-4644
Country	:	US
Telephone Number	:	781-619-9324
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 TECHNOLOGY DR
Second Line	:
City	:	NORTH CHELMSFORD
State	:	MA
Zip	:	01863-2438
Country	:	US
Telephone Number	:	978-458-0099
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT VICE PRESIDENT, LEGAL
Name	:	MS. SHARON MAKOWSKY
Credential	:
Telephone Number	:	646-677-8753

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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