Provider Demographics
NPI:1861865065
Name:WATERVIEW LODGE LLC
Entity Type:Organization
Organization Name:WATERVIEW LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:DSC,RD,LDN,RN,NHA
Authorized Official - Phone:508-879-6420
Mailing Address - Street 1:32 NEWTONVILLE AVE
Mailing Address - Street 2:P.O. BOX 788
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1939
Mailing Address - Country:US
Mailing Address - Phone:508-879-6420
Mailing Address - Fax:
Practice Address - Street 1:250 W UNION ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-1420
Practice Address - Country:US
Practice Address - Phone:508-879-6420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility