Provider Demographics
NPI:1831198555
Name:64 PERFORMANCE DRIVE OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:64 PERFORMANCE DRIVE 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 1:64 PERFORMANCE DR.
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189
Mailing Address - Country:US
Mailing Address - Phone:781-340-9800
Mailing Address - Fax:781-340-1771
Practice Address - Street 1:64 PERFORMANCE DR.
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189
Practice Address - Country:US
Practice Address - Phone:781-340-9800
Practice Address - Fax:781-340-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
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
MA0926841Medicaid
MA0926841Medicaid