Provider Demographics
NPI:1831293240
Name:PIETY CORNER NURSING HOME
Entity Type:Organization
Organization Name:PIETY CORNER NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTAVINA
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:781-894-5264
Mailing Address - Street 1:325 BACON ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-7519
Mailing Address - Country:US
Mailing Address - Phone:781-894-5264
Mailing Address - Fax:781-894-6011
Practice Address - Street 1:325 BACON ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7519
Practice Address - Country:US
Practice Address - Phone:781-894-5264
Practice Address - Fax:781-894-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3982310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0927163Medicaid
MA0927163Medicaid