Provider Demographics
NPI:1508852757
Name:WACHUSETT EXTENDED CARE FACILITY INC
Entity Type:Organization
Organization Name:WACHUSETT EXTENDED CARE FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-829-1104
Mailing Address - Street 1:54 BOYDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-2570
Mailing Address - Country:US
Mailing Address - Phone:508-829-1110
Mailing Address - Fax:508-829-1234
Practice Address - Street 1:56 BOYDEN ROAD
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-2570
Practice Address - Country:US
Practice Address - Phone:508-829-1104
Practice Address - Fax:508-829-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0930172313M00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0920304Medicaid
MA0930172Medicaid
MA0930172Medicaid
MA225542Medicare Oscar/Certification