Provider Demographics
NPI:1962451542
Name:SENIOR RESIDENTIAL CARE/WORCESTER, INC.
Entity Type:Organization
Organization Name:SENIOR RESIDENTIAL CARE/WORCESTER, INC.
Other - Org Name:WINGATE AT WORCESTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:781-707-9510
Mailing Address - Street 1:63 KENDRICK ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2708
Mailing Address - Country:US
Mailing Address - Phone:781-707-9085
Mailing Address - Fax:781-707-9285
Practice Address - Street 1:59 ACTON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4829
Practice Address - Country:US
Practice Address - Phone:508-791-3147
Practice Address - Fax:508-753-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0723282E00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0068047Medicaid
NY00312074Medicaid
NY02998176Medicaid
NY00880373Medicaid
NY00880364Medicaid
MA110026673BMedicaid
CT000026450Medicaid
MA110026673AMedicaid
NH30103097Medicaid
NY00880364Medicaid