Healthcare Provider Details

I. General information

NPI: 1558503342
Provider Name (Legal Business Name): VIDADE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 WASHINGTON ST 1960
BOSTON MA
02118-3219
US

IV. Provider business mailing address

1960 WASHINGTON ST 1960
BOSTON MA
02118-3219
US

V. Phone/Fax

Practice location:
  • Phone: 617-516-0280
  • Fax:
Mailing address:
  • Phone: 617-516-0280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. VIDADE M RATEAU
Title or Position: MHA
Credential:
Phone: 857-753-9760