Provider Demographics
NPI:1942209721
Name:312 MILLBURY AVENUE OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:312 MILLBURY AVENUE OPERATING COMPANY, LLC
Other - Org Name:MILLBURY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, SPECIAL PROJECTS
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-930-6051
Mailing Address - Street 1:312 MILLBURY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01529
Mailing Address - Country:US
Mailing Address - Phone:508-793-0088
Mailing Address - Fax:508-793-1671
Practice Address - Street 1:312 MILLBURY AVENUE
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01529
Practice Address - Country:US
Practice Address - Phone:508-793-0088
Practice Address - Fax:508-793-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0926817Medicaid
MA0926817Medicaid