MEDICARE: LORD NATHAN REST HOME

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	1058	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5508452	OTHER	MA	PROVIDER NUMBER

General Provider Information

NPI Number	:	1790802510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORD NATHAN REST HOME

Provider Business Mailing Address
First Line	:	175 BOWDOIN ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01109-4050
Country	:	US
Telephone Number	:	413-737-2148
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 BOWDOIN ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01109-4050
Country	:	US
Telephone Number	:	413-737-2148
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MICHAEL JOSEPH
Credential	:
Telephone Number	:	413-737-2148

Provider Enumeration Date	:	03/25/2007
Last Update Date	:	08/22/2020

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Directions to “LORD NATHAN REST HOME ” Practice Location

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