Provider Demographics
NPI:1790772192
Name:ELLIS NURSING HOME, INC.
Entity Type:Organization
Organization Name:ELLIS NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FEDERICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-237-8503
Mailing Address - Street 1:135 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3946
Mailing Address - Country:US
Mailing Address - Phone:781-762-6880
Mailing Address - Fax:
Practice Address - Street 1:135 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3946
Practice Address - Country:US
Practice Address - Phone:781-762-6880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0793207QG0300X
261QR0400X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0908029Medicaid
2222521101OtherBCBS
903249OtherHDHC
903249OtherHDHC