Provider Demographics
NPI:1811024664
Name:SUDBURY PINES EXTENDED CARE FACILITY
Entity Type:Organization
Organization Name:SUDBURY PINES EXTENDED CARE FACILITY
Other - Org Name:SUDBURY PINES HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:617-512-6625
Mailing Address - Street 1:642 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-3302
Mailing Address - Country:US
Mailing Address - Phone:617-512-6625
Mailing Address - Fax:978-443-9510
Practice Address - Street 1:642 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-3302
Practice Address - Country:US
Practice Address - Phone:617-512-6625
Practice Address - Fax:978-443-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221553251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024524AMedicaid
MA0611000Medicaid
MA110024524AMedicaid