Provider Demographics
NPI:1346249075
Name:70 GRANITE STREET OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:70 GRANITE STREET OPERATING COMPANY, LLC
Other - Org Name:NORTH SHORE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4004
Mailing Address - Street 1:70 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2915
Mailing Address - Country:US
Mailing Address - Phone:781-581-2400
Mailing Address - Fax:781-581-3080
Practice Address - Street 1:70 GRANITE ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2915
Practice Address - Country:US
Practice Address - Phone:781-581-2400
Practice Address - Fax:781-581-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0926884Medicaid
MA0926884Medicaid