Provider Demographics
NPI:1720496318
Name:PEREGRINE SENIOR LIVING OF TEWKSBURY, LLC
Entity Type:Organization
Organization Name:PEREGRINE SENIOR LIVING OF TEWKSBURY, LLC
Other - Org Name:PEREGRINE'S LANDING AT TEWKSBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-476-5610
Mailing Address - Street 1:217 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1937
Mailing Address - Country:US
Mailing Address - Phone:315-476-5610
Mailing Address - Fax:315-475-8729
Practice Address - Street 1:1009 MAIN ST # 2850
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4737
Practice Address - Country:US
Practice Address - Phone:985-377-1622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-26
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility