Provider Demographics
NPI:1891749222
Name:BROCKTON MANOR, INC.
Entity Type:Organization
Organization Name:BROCKTON MANOR, INC.
Other - Org Name:REGENT PARK MANOR AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-905-5200
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-0010
Mailing Address - Country:US
Mailing Address - Phone:731-847-6343
Mailing Address - Fax:731-847-4200
Practice Address - Street 1:41 LIBBY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2949
Practice Address - Country:US
Practice Address - Phone:508-588-1450
Practice Address - Fax:508-583-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0797314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
22-5566Medicare ID - Type Unspecified