Provider Demographics
NPI:1225162415
Name:COREY ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:COREY ASSISTED LIVING LLC
Other - Org Name:PROVIDENCE HOUSE SENIOR LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-731-0505
Mailing Address - Street 1:180 COREY RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-8239
Mailing Address - Country:US
Mailing Address - Phone:617-731-0505
Mailing Address - Fax:617-731-0599
Practice Address - Street 1:180 COREY RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-8239
Practice Address - Country:US
Practice Address - Phone:617-731-0505
Practice Address - Fax:617-731-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1906143Medicare ID - Type UnspecifiedGAFC