Healthcare Provider Details

I. General information

NPI: 1013242239
Provider Name (Legal Business Name): TRUSTEES OF BOSTON UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 COMMONWEALTH AVE. 6TH FLOOR
BOSTON MA
02215-1605
US

IV. Provider business mailing address

635 COMMONWEALTH AVE 6TH FLOOR
BOSTON MA
02215-1605
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-2721
  • Fax: 617-358-5460
Mailing address:
  • Phone: 617-353-2721
  • Fax: 617-358-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: STACEY ZAWACKI
Title or Position: DIRECTOR
Credential: DRPH, RD
Phone: 617-358-5065