Provider Demographics
NPI:1184207557
Name:BEAR MT NORTH ANDOVER, LLC
Entity Type:Organization
Organization Name:BEAR MT NORTH ANDOVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:860-880-8202
Mailing Address - Street 1:130 S MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1741
Mailing Address - Country:US
Mailing Address - Phone:860-880-8202
Mailing Address - Fax:
Practice Address - Street 1:140 PRESCOTT ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-1826
Practice Address - Country:US
Practice Address - Phone:978-685-8086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility