MEDICARE: SPRRRRR LC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1346662319	OTHER		NPI

General Provider Information

NPI Number	:	1467923045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRRRRR LC.

Provider Business Mailing Address
First Line	:	91 COLORADO ST
Second Line	:
City	:	MATTAPAN
State	:	MA
Zip	:	02126-1347
Country	:	US
Telephone Number	:	857-261-2011
Fax Number	:	617-698-0871

Provider Business Practice Location Address
First Line	:	91 COLORADO ST
Second Line	:
City	:	MATTAPAN
State	:	MA
Zip	:	02126-1347
Country	:	US
Telephone Number	:	857-261-2011
Fax Number	:	617-698-0871

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MISS CICELY PAYNE
Credential	:
Telephone Number	:	857-261-2011

Provider Enumeration Date	:	12/08/2018
Last Update Date	:	12/08/2018

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