Provider Demographics
NPI:1639230584
Name:84 ELM ST., INC.
Entity Type:Organization
Organization Name:84 ELM ST., INC.
Other - Org Name:TIMOTHY DANIELS HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:THISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-762-0703
Mailing Address - Street 1:80 ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5237
Mailing Address - Country:US
Mailing Address - Phone:781-762-0703
Mailing Address - Fax:781-762-2099
Practice Address - Street 1:84 ELM ST
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-2138
Practice Address - Country:US
Practice Address - Phone:508-429-4566
Practice Address - Fax:508-429-4581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0374314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0907022Medicaid
MA0692780001Medicare NSC
MA225709Medicare Oscar/Certification