Healthcare Provider Details

I. General information

NPI: 1386773273
Provider Name (Legal Business Name): COMMONWEALTH OF MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 NAGOG PARK SUITE 2000
ACTON MA
01720
US

IV. Provider business mailing address

40 BROAD STREET 4TH FLOOR
BOSTON MA
02109
US

V. Phone/Fax

Practice location:
  • Phone: 976-206-2050
  • Fax:
Mailing address:
  • Phone: 617-727-5608
  • Fax: 617-624-7577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DYLAN LATTIMORE
Title or Position: DEPUTY COMMISSIONER OF ADMINSTRATI
Credential:
Phone: 857-408-0675