Healthcare Provider Details

I. General information

NPI: 1184684060
Provider Name (Legal Business Name): JACK P SYLVIA MED
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 PINE STREET
FALL RIVER MA
02720
US

IV. Provider business mailing address

67 BRYANT ST
BERKLEY MA
02779-1504
US

V. Phone/Fax

Practice location:
  • Phone: 508-678-0091
  • Fax: 508-324-9002
Mailing address:
  • Phone: 508-821-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3028159
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: