Provider Demographics
NPI:1457481145
Name:MT IDA REST HOME, INC.
Entity Type:Organization
Organization Name:MT IDA REST HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:D, SC
Authorized Official - Phone:508-665-6050
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-0001
Mailing Address - Country:US
Mailing Address - Phone:508-665-6050
Mailing Address - Fax:508-875-8872
Practice Address - Street 1:32 NEWTONVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWTONVILLE
Practice Address - State:MA
Practice Address - Zip Code:02458-1939
Practice Address - Country:US
Practice Address - Phone:508-665-6050
Practice Address - Fax:508-875-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA872314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5507723Medicaid