Provider Demographics
NPI:1205818333
Name:ANNEMARK NURSING HOME, INC.
Entity Type:Organization
Organization Name:ANNEMARK NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-322-4861
Mailing Address - Street 1:133 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1114
Mailing Address - Country:US
Mailing Address - Phone:781-322-4861
Mailing Address - Fax:781-324-1191
Practice Address - Street 1:133 SALEM ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1114
Practice Address - Country:US
Practice Address - Phone:781-322-4861
Practice Address - Fax:781-324-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0864314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0914525Medicaid
MA225432OtherMEDEX
MA225432OtherBLUE CROSS BLUE SHIELD
MA670680OtherTUFTS PROVIDER NUMBER
MA=========OtherFEDERAL TAX ID NUMBER
MA0914525Medicaid