Provider Demographics
NPI:1821195165
Name:MARIAN MANOR, FOR THE AGED AND INFIRM, INC.
Entity Type:Organization
Organization Name:MARIAN MANOR, FOR THE AGED AND INFIRM, INC.
Other - Org Name:MARIAN MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-268-3333
Mailing Address - Street 1:130 DORCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2642
Mailing Address - Country:US
Mailing Address - Phone:617-268-3333
Mailing Address - Fax:617-268-4589
Practice Address - Street 1:130 DORCHESTER STREET
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2642
Practice Address - Country:US
Practice Address - Phone:617-268-3333
Practice Address - Fax:617-268-4589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225415314000000X
MA0506314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110025765AMedicaid
225415Medicare Oscar/Certification