Healthcare Provider Details

I. General information

NPI: 1801087580
Provider Name (Legal Business Name): USCG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
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: 617-223-3121
  • Fax:
Mailing address:
  • Phone: 617-223-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY MICHAEL AYKROYD
Title or Position: IDHS
Credential:
Phone: 617-223-3121