Provider Demographics
NPI:1417347170
Name:WEST REVERE HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:WEST REVERE HEALTH CENTER, LLC
Other - Org Name:WEST REVERE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF VENDOR RELATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-710-4431
Mailing Address - Street 1:2363 LAKEWOOD RD
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-1524
Mailing Address - Country:US
Mailing Address - Phone:732-710-4431
Mailing Address - Fax:
Practice Address - Street 1:133 SALEM ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1114
Practice Address - Country:US
Practice Address - Phone:781-322-4861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0864314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA225432Medicare Oscar/Certification