Provider Demographics
NPI:1306646088
Name:675 SOUTH MAIN STREET OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:675 SOUTH MAIN STREET OPERATING COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-354-0255
Mailing Address - Street 1:173 BRIDGE PLZ N FL 6
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:MA
Practice Address - Zip Code:02067-2834
Practice Address - Country:US
Practice Address - Phone:781-784-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility