Provider Demographics
NPI:1245570779
Name:VK NEWBURYPORT, LLC
Entity Type:Organization
Organization Name:VK NEWBURYPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-705-4802
Mailing Address - Street 1:46 STAUDERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 LOW ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3519
Practice Address - Country:US
Practice Address - Phone:978-465-5361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095728AMedicaid
MA110095728AMedicaid