Provider Demographics
NPI:1093184715
Name:279 CABOT STREET OPERATIONS LLC
Entity Type:Organization
Organization Name:279 CABOT STREET OPERATIONS LLC
Other - Org Name:RENAISSANCE MANOR ON CABOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:279 CABOT ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-3139
Mailing Address - Country:US
Mailing Address - Phone:413-536-3435
Mailing Address - Fax:413-536-3436
Practice Address - Street 1:279 CABOT ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3139
Practice Address - Country:US
Practice Address - Phone:413-536-3435
Practice Address - Fax:413-536-3436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility