Provider Demographics
NPI:1578898755
Name:MARY'S MEADOW AT PROVIDENCE PLACE,INC.
Entity Type:Organization
Organization Name:MARY'S MEADOW AT PROVIDENCE PLACE,INC.
Other - Org Name:MARY'S MEADOW AT PROVIDENCE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-539-2942
Mailing Address - Street 1:5 GAMELIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-4072
Mailing Address - Country:US
Mailing Address - Phone:413-420-2500
Mailing Address - Fax:413-322-7096
Practice Address - Street 1:5 GAMELIN ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4072
Practice Address - Country:US
Practice Address - Phone:413-420-2500
Practice Address - Fax:413-322-7096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0FIT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
225738Medicare Oscar/Certification