Provider Demographics
NPI:1275515439
Name:ST. JOSEPH MANOR HEALTH CARE, INC.
Entity Type:Organization
Organization Name:ST. JOSEPH MANOR HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-583-5834
Mailing Address - Street 1:215 THATCHER ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3949
Mailing Address - Country:US
Mailing Address - Phone:508-583-5834
Mailing Address - Fax:508-583-8551
Practice Address - Street 1:215 THATCHER ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3949
Practice Address - Country:US
Practice Address - Phone:508-583-5834
Practice Address - Fax:508-583-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA881313M00000X
MA0585314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0906166Medicaid
225414Medicare Oscar/Certification