Provider Demographics
NPI:1235112012
Name:TI - DERRY LLC
Entity Type:Organization
Organization Name:TI - DERRY LLC
Other - Org Name:DERRY HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-444-0900
Mailing Address - Street 1:20 CHESTER RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1636
Mailing Address - Country:US
Mailing Address - Phone:603-432-3801
Mailing Address - Fax:603-437-8287
Practice Address - Street 1:20 CHESTER RD
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1636
Practice Address - Country:US
Practice Address - Phone:603-432-3801
Practice Address - Fax:603-437-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02959314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99750142Medicaid
NH305095Medicare Oscar/Certification