MEDICARE: 64 PERFORMANCE DRIVE OPERATING COMPANY, 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	314000000X	Skilled Nursing Facility		MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831198555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	64 PERFORMANCE DRIVE OPERATING COMPANY, LLC

Provider Business Mailing Address
First Line	:	64 PERFORMANCE DR.
Second Line	:
City	:	WEYMOUTH
State	:	MA
Zip	:	02189
Country	:	US
Telephone Number	:	781-340-9800
Fax Number	:	781-340-1771

Provider Business Practice Location Address
First Line	:	64 PERFORMANCE DR.
Second Line	:
City	:	WEYMOUTH
State	:	MA
Zip	:	02189
Country	:	US
Telephone Number	:	781-340-9800
Fax Number	:	781-340-1771

Authorized Official
Title or Position	:	VP, SPECIAL PROJECTS
Name	:	EMILY VAZQUEZ
Credential	:
Telephone Number	:	978-930-6051

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	12/15/2023

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