Provider Demographics
NPI:1245403963
Name:MEDWAY COUNTRY MANOR, INC.
Entity Type:Organization
Organization Name:MEDWAY COUNTRY MANOR, INC.
Other - Org Name:GENERATIONS OUTPATIENT WELLNESS & REHAB - SPEECH THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:508-533-6634
Mailing Address - Street 1:115 HOLLISTON ST
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1954
Mailing Address - Country:US
Mailing Address - Phone:508-533-9893
Mailing Address - Fax:508-533-7048
Practice Address - Street 1:115 HOLLISTON ST
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1954
Practice Address - Country:US
Practice Address - Phone:508-533-9893
Practice Address - Fax:508-533-7048
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDWAY COUNTRY MANOR, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0910481Medicaid
MA225412Medicare Oscar/Certification