Healthcare Provider Details

I. General information

NPI: 1780661439
Provider Name (Legal Business Name): JAMIE KALEB LANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 COMMERCIAL ST
BOSTON MA
02109-1027
US

IV. Provider business mailing address

427 COMMERCIAL ST
BOSTON MA
02109-1027
US

V. Phone/Fax

Practice location:
  • Phone: 617-223-5821
  • Fax: 617-223-3038
Mailing address:
  • Phone: 617-223-5821
  • Fax: 617-223-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: