Provider Demographics
NPI:1962491704
Name:EDGAR P BENJAMIN HEALTHCARE CENTER, INC
Entity Type:Organization
Organization Name:EDGAR P BENJAMIN HEALTHCARE CENTER, INC
Other - Org Name:BENJAMIN HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT & CEO
Authorized Official - Phone:617-738-1500
Mailing Address - Street 1:120 FISHER AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3320
Mailing Address - Country:US
Mailing Address - Phone:617-738-1500
Mailing Address - Fax:617-738-6472
Practice Address - Street 1:120 FISHER AVENUE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-3320
Practice Address - Country:US
Practice Address - Phone:617-738-1500
Practice Address - Fax:617-738-6472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0785314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0998613Medicaid
MA225654Medicare Oscar/Certification
MA0585220001Medicare NSC