Provider Demographics
NPI:1265483796
Name:SRC SPRINGFIELD, INC.
Entity Type:Organization
Organization Name:SRC SPRINGFIELD, INC.
Other - Org Name:WINGATE AT SPRINGFIELD REHAB. & SKILLED NSG. RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:781-707-9510
Mailing Address - Street 1:63 KENDRICK ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2708
Mailing Address - Country:US
Mailing Address - Phone:781-707-9085
Mailing Address - Fax:781-707-9285
Practice Address - Street 1:215 BICENTENNIAL HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1962
Practice Address - Country:US
Practice Address - Phone:413-796-7511
Practice Address - Fax:413-783-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0899314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026479AMedicaid
MA22-5392Medicare ID - Type Unspecified