Provider Demographics
NPI:1396109195
Name:BANE COLONIAL, LLC
Entity type:Organization
Organization Name:BANE COLONIAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-878-6700
Mailing Address - Street 1:350 GRANITE ST STE 2203
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4963
Mailing Address - Country:US
Mailing Address - Phone:781-474-2263
Mailing Address - Fax:781-871-3986
Practice Address - Street 1:125 BROAD ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02188-2336
Practice Address - Country:US
Practice Address - Phone:781-337-3121
Practice Address - Fax:781-337-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70012222205201OtherBLUE CROSS
MA110117821AMedicaid
MA225059Medicare Oscar/Certification