Provider Demographics
NPI:1932644994
Name:239 CROSS ROAD LLC
Entity Type:Organization
Organization Name:239 CROSS ROAD LLC
Other - Org Name:AUTUMN GLEN AT DARTMOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-404-3534
Mailing Address - Street 1:239 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1992
Mailing Address - Country:US
Mailing Address - Phone:508-992-8880
Mailing Address - Fax:
Practice Address - Street 1:239 CROSS RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1992
Practice Address - Country:US
Practice Address - Phone:508-992-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility