Basic Information
| Provider Information | |||||||||
| NPI: | 1255335766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE NORTHEAST HEALTH GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | GOVERNOR'S CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 PALM BEACH BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618017600 | ||||||||
| FaxNumber: | 4142684811 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010852927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135625464 | ||||||||
| FaxNumber: | 4135689212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | JAFFE | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2153466454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0041 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0922455 | 05 | MA | MEDICAID |