Provider Demographics
NPI:1023017951
Name:265 ESSEX STREET OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:265 ESSEX STREET OPERATING COMPANY, LLC
Other - Org Name:ESSEX PARK REHABILITATION & NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:A.
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4000
Mailing Address - Street 1:265 ESSEX STREET
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-927-3260
Mailing Address - Fax:978-922-8347
Practice Address - Street 1:265 ESSEX STREET
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-927-3260
Practice Address - Fax:978-922-8347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0928291Medicaid
MA225270Medicare ID - Type Unspecified