Provider Demographics
NPI:1528584638
Name:804 EAST 7TH STREET OPERATOR LLC
Entity Type:Organization
Organization Name:804 EAST 7TH STREET OPERATOR LLC
Other - Org Name:SOUTH BOSTON HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:STEPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-943-7747
Mailing Address - Street 1:804 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4346
Mailing Address - Country:US
Mailing Address - Phone:617-268-8968
Mailing Address - Fax:
Practice Address - Street 1:804 E 7TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4346
Practice Address - Country:US
Practice Address - Phone:617-268-8968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility