Provider Demographics
NPI:1699772376
Name:LIGHTHOUSE OF REVERE, INC.
Entity type:Organization
Organization Name:LIGHTHOUSE OF REVERE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-286-3100
Mailing Address - Street 1:204 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4923
Mailing Address - Country:US
Mailing Address - Phone:781-286-3100
Mailing Address - Fax:781-286-4109
Practice Address - Street 1:204 PROCTOR AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4923
Practice Address - Country:US
Practice Address - Phone:781-286-3100
Practice Address - Fax:781-286-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0880314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0922226Medicaid
MA0922226Medicaid