Healthcare Provider Details

I. General information

NPI: 1588061550
Provider Name (Legal Business Name): VHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-4332
  • Fax:
Mailing address:
  • Phone: 857-364-4332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number257436
License Number StateMA

VIII. Authorized Official

Name: MS. RACHEL BEREIWERISO
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 857-364-4332