Provider Demographics
NPI:1104144765
Name:CLIFTON GERIATRIC CENTER
Entity type:Organization
Organization Name:CLIFTON GERIATRIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REHABILITATION
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:508-675-7589
Mailing Address - Street 1:500 WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02725-2051
Mailing Address - Country:US
Mailing Address - Phone:508-675-7589
Mailing Address - Fax:508-675-0132
Practice Address - Street 1:500 WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02725-2051
Practice Address - Country:US
Practice Address - Phone:508-675-7589
Practice Address - Fax:508-675-0132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLIFTON GERIATRIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-06
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4762235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty