Provider Demographics
NPI:1982179610
Name:BEAR MT MATTAPAN, LLC
Entity Type:Organization
Organization Name:BEAR MT MATTAPAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-904-7462
Mailing Address - Street 1:13 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1735
Mailing Address - Country:US
Mailing Address - Phone:203-904-7462
Mailing Address - Fax:
Practice Address - Street 1:405 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2210
Practice Address - Country:US
Practice Address - Phone:617-296-5585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAR MOUNTAIN HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility