Provider Demographics
NPI:1902817299
Name:184 MAIN LLC
Entity Type:Organization
Organization Name:184 MAIN LLC
Other - Org Name:ROYAL FAIRHAVEN NURSING & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-743-8159
Mailing Address - Street 1:184 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719
Mailing Address - Country:US
Mailing Address - Phone:508-997-3193
Mailing Address - Fax:508-991-5615
Practice Address - Street 1:184 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719
Practice Address - Country:US
Practice Address - Phone:508-997-3193
Practice Address - Fax:508-991-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0646314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5457520OtherAETNA
MA001391OtherSENIOR WHOLE HEALTH
MA0940119Medicaid
MA991098OtherUNITED HEALTH CARE
MA225117Medicare Oscar/Certification
MA991098OtherUNITED HEALTH CARE