Provider Demographics
NPI:1740269893
Name:SOUTH BOSTON NURSING LLC
Entity type:Organization
Organization Name:SOUTH BOSTON NURSING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-297-8626
Mailing Address - Street 1:50 KERRY PL
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-4775
Mailing Address - Country:US
Mailing Address - Phone:781-619-0250
Mailing Address - Fax:
Practice Address - Street 1:804 E 7TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4346
Practice Address - Country:US
Practice Address - Phone:617-268-8968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0458314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0926108Medicaid
MA0926108Medicaid