Provider Demographics
NPI:1063838282
Name:GAHCR II HYDE PARK SNF TRS SUB, LLC
Entity Type:Organization
Organization Name:GAHCR II HYDE PARK SNF TRS SUB, LLC
Other - Org Name:PARK PLACE REHABILITATION AND SKILLED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-474-2263
Mailing Address - Street 1:113 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3021
Mailing Address - Country:US
Mailing Address - Phone:617-361-2388
Mailing Address - Fax:617-364-3112
Practice Address - Street 1:113 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3021
Practice Address - Country:US
Practice Address - Phone:617-361-2388
Practice Address - Fax:617-364-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
225375Medicare Oscar/Certification