Provider Demographics
NPI:1922557487
Name:WV-BROCKTON SNF, LLC
Entity Type:Organization
Organization Name:WV-BROCKTON SNF, LLC
Other - Org Name:BROCKTON HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:DENNEHY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:978-886-3336
Mailing Address - Street 1:36 WASHINGTON ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1900
Mailing Address - Country:US
Mailing Address - Phone:978-886-3336
Mailing Address - Fax:
Practice Address - Street 1:2 BEAUMONT AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3302
Practice Address - Country:US
Practice Address - Phone:508-559-2521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WACHUSETT VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0695314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11010204AMedicaid
MA225221Medicare Oscar/Certification