Provider Demographics
NPI:1770578627
Name:DARTMOUTH MANOR HOME INC
Entity type:Organization
Organization Name:DARTMOUTH MANOR HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-399-8487
Mailing Address - Street 1:66 TURNSTONE LN
Mailing Address - Street 2:
Mailing Address - City:SEEKONK
Mailing Address - State:MA
Mailing Address - Zip Code:02771-2712
Mailing Address - Country:US
Mailing Address - Phone:508-254-3078
Mailing Address - Fax:508-399-7191
Practice Address - Street 1:70 STATE RD
Practice Address - Street 2:
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-2920
Practice Address - Country:US
Practice Address - Phone:508-993-9255
Practice Address - Fax:508-993-9260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA836311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5507308Medicaid