Provider Demographics
NPI:1790776698
Name:SISTERS OF PROVIDENCE CARE CTRS INC
Entity Type:Organization
Organization Name:SISTERS OF PROVIDENCE CARE CTRS INC
Other - Org Name:BEAVEN KELLY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO, MERCY CONTINUING CARE NETWORK
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MCLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-539-2917
Mailing Address - Street 1:1221 MAIN ST
Mailing Address - Street 2:CATHERINE HORAN BUILDING, SUITE 105
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-5394
Mailing Address - Country:US
Mailing Address - Phone:413-539-2618
Mailing Address - Fax:413-539-2859
Practice Address - Street 1:25 BRIGHTSIDE DR
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4033
Practice Address - Country:US
Practice Address - Phone:413-532-4892
Practice Address - Fax:413-535-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA879311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5508304Medicaid