Healthcare Provider Details

I. General information

NPI: 1639718596
Provider Name (Legal Business Name): VITRA ADULT DAY HEALTH I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2019
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N PEARL ST
BROCKTON MA
02301-1708
US

IV. Provider business mailing address

10 N PEARL ST
BROCKTON MA
02301-1708
US

V. Phone/Fax

Practice location:
  • Phone: 508-594-8708
  • Fax:
Mailing address:
  • Phone: 508-594-8708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD SPIVAK
Title or Position: MANAGER
Credential:
Phone: 508-594-8288