Provider Demographics
NPI:1104940287
Name:PARK AVENUE NURSING & REHABILITATION CENTER INC
Entity type:Organization
Organization Name:PARK AVENUE NURSING & REHABILITATION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALESSANDRONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-648-9530
Mailing Address - Street 1:146 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5829
Mailing Address - Country:US
Mailing Address - Phone:781-648-9530
Mailing Address - Fax:781-646-3668
Practice Address - Street 1:146 PARK AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5829
Practice Address - Country:US
Practice Address - Phone:781-648-9530
Practice Address - Fax:781-646-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0777314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7100196OtherEVERCARE PROVIDER #
MA0904988Medicaid
MA906183OtherHARVARD PILGRIM PROVID #
MA904423OtherTUFTS HEALTH PLAN PROV #
MA2222558401OtherBLUE CROSS PROVIDER #
MA=========OtherFEDERAL TAX ID#
MA904423OtherTUFTS HEALTH PLAN PROV #