Provider Demographics
NPI:1457346504
Name:ISLAND TERRACE, INC.
Entity Type:Organization
Organization Name:ISLAND TERRACE, INC.
Other - Org Name:ISLAND TERRACE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLLES
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:508-947-0151
Mailing Address - Street 1:57 LONG POINT RD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-2124
Mailing Address - Country:US
Mailing Address - Phone:508-947-0151
Mailing Address - Fax:508-946-5335
Practice Address - Street 1:57 LONG POINT RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-2124
Practice Address - Country:US
Practice Address - Phone:508-947-0151
Practice Address - Fax:508-946-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0614314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0911798Medicaid
MA225405Medicare Oscar/Certification
0454170001Medicare NSC