Provider Demographics
NPI:1720268402
Name:EPOCH ON BLACKSTONE BOULEVARD, LLC
Entity Type:Organization
Organization Name:EPOCH ON BLACKSTONE BOULEVARD, LLC
Other - Org Name:EPOCH SENIOR HEALTHCARE ON BLACKSTONE BOULEVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:
Authorized Official - Last Name:PFAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-810-1240
Mailing Address - Street 1:51 SAWYER RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3448
Mailing Address - Country:US
Mailing Address - Phone:781-810-1240
Mailing Address - Fax:
Practice Address - Street 1:353 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4936
Practice Address - Country:US
Practice Address - Phone:401-273-6565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILTC00724314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI415126Medicare Oscar/Certification