Provider Demographics
NPI:1316323074
Name:120 MURRAY STREET OPERATIONS LLC
Entity type:Organization
Organization Name:120 MURRAY STREET OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:120 MURRAY STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-391-0800
Mailing Address - Fax:781-391-0801
Practice Address - Street 1:120 MURRAY STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-391-0800
Practice Address - Fax:781-391-0801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-05
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA00000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA49447611423151OtherAETNA