Provider Demographics
NPI:1639286750
Name:AVERY MANOR NURSING, L.L.C.
Entity Type:Organization
Organization Name:AVERY MANOR NURSING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7563
Mailing Address - Street 1:680 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WEST ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-1319
Practice Address - Country:US
Practice Address - Phone:781-234-6300
Practice Address - Fax:781-234-6832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0927961Medicaid
MA907779OtherEVERCARE
MA000000023951OtherBMC HEALTH NET
MA2222567401OtherBLUE CROSS BLUE SHIELD
MA637422OtherMULTIPLAN
MA0020004OtherMARTINS POINT
MA0926272OtherMVP
MA71-00783OtherCIGNA
MA0926272OtherMVP