Provider Demographics
NPI:1790775336
Name:MARY LYON NURSING AND REHABILITATION CENTER
Entity Type:Organization
Organization Name:MARY LYON NURSING AND REHABILITATION CENTER
Other - Org Name:RADIUS 91 LYONS OPERATING, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE REGIONAL MANAGE
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECOTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-335-3318
Mailing Address - Street 1:34 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01036-9642
Mailing Address - Country:US
Mailing Address - Phone:413-566-5511
Mailing Address - Fax:413-566-8488
Practice Address - Street 1:34 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:MA
Practice Address - Zip Code:01036-9642
Practice Address - Country:US
Practice Address - Phone:413-566-5511
Practice Address - Fax:413-566-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0057314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0929191Medicaid
MA0929191Medicaid
MA0929191Medicaid