Provider Demographics
NPI:1497740773
Name:EASTERN ORTHODOX MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:EASTERN ORTHODOX MANAGEMENT CORPORATION
Other - Org Name:HOLY TRINITY NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:IT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IOANNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRONIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-852-1000
Mailing Address - Street 1:300 BARBER AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2476
Mailing Address - Country:US
Mailing Address - Phone:508-852-1000
Mailing Address - Fax:508-854-1622
Practice Address - Street 1:300 BARBER AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2476
Practice Address - Country:US
Practice Address - Phone:508-852-1000
Practice Address - Fax:508-854-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0970314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2222564801OtherBLUE CROSS
MA7100305OtherEVERCARE
MA0921858Medicaid
MA802933OtherTUFTS
MA70012222564801OtherMEDEX
MA904691OtherPILGRIM
225648Medicare ID - Type Unspecified