Healthcare Provider Details

I. General information

NPI: 1992950505
Provider Name (Legal Business Name): HAITIAN ADULT DAYCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 FRONTENAC ST
DORCHESTER CENTER MA
02124-3902
US

IV. Provider business mailing address

6 FRONTENAC ST
DORCHESTER CENTER MA
02124-3902
US

V. Phone/Fax

Practice location:
  • Phone: 617-288-4155
  • Fax: 617-288-4177
Mailing address:
  • Phone: 617-288-4155
  • Fax: 617-288-4177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1907034
License Number StateMA

VIII. Authorized Official

Name: IGOR SHREYER
Title or Position: MEMBER
Credential:
Phone: 857-222-9940