Healthcare Provider Details

I. General information

NPI: 1467667899
Provider Name (Legal Business Name): RGB COOPERATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 COMMERCIAL ST
BOSTON MA
02109-1027
US

IV. Provider business mailing address

209 SAVANNAH AVE APT 2
MATTAPAN MA
02126-3255
US

V. Phone/Fax

Practice location:
  • Phone: 617-223-3121
  • Fax: 617-223-3038
Mailing address:
  • Phone: 617-648-6243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: VIVIAN RIVERA
Title or Position: CMA MEDICAL ASSISTANT
Credential:
Phone: 617-648-6243