Healthcare Provider Details

I. General information

NPI: 1124259056
Provider Name (Legal Business Name): FENWAY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

IV. Provider business mailing address

1340 BOYLSTON STREET
BOSTON MA
02215
US

V. Phone/Fax

Practice location:
  • Phone: 617-927-6127
  • Fax:
Mailing address:
  • Phone: 617-927-6127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. KARA ROBERTS
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 617-927-6479