Provider Demographics
NPI:1154988145
Name:KRE HUSKY CHESTNUT PARK LICENSEE LLC
Entity type:Organization
Organization Name:KRE HUSKY CHESTNUT PARK LICENSEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRAPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-489-7100
Mailing Address - Street 1:201 JONES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 SUTHERLAND RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-7132
Practice Address - Country:US
Practice Address - Phone:617-396-4031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility