Provider Demographics
NPI:1770582439
Name:PARK, MARION AND VERNON STREETS OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:PARK, MARION AND VERNON STREETS OPERATING COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, SPECIAL PROJECTS
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-930-6051
Mailing Address - Street 1:99 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-731-1050
Mailing Address - Fax:617-731-6516
Practice Address - Street 1:99 PARK STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-731-1050
Practice Address - Fax:617-731-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0928496Medicaid
MA225509Medicare ID - Type Unspecified