Healthcare Provider Details

I. General information

NPI: 1225614548
Provider Name (Legal Business Name): IMEDICAL365 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 02/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 W MAIN ST
AVON MA
02322-1330
US

IV. Provider business mailing address

PO BOX 1911
BROCKTON MA
02303-1911
US

V. Phone/Fax

Practice location:
  • Phone: 508-326-0496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOEL CLERVILLE
Title or Position: DIRECTOR
Credential: NP
Phone: 508-326-0496