Healthcare Provider Details

I. General information

NPI: 1265672265
Provider Name (Legal Business Name): FUENTE DE VIDA ADULT DAY CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BRADLEE ST
HYDE PARK MA
02136-2226
US

IV. Provider business mailing address

130 BRADLEE ST
HYDE PARK MA
02136-2226
US

V. Phone/Fax

Practice location:
  • Phone: 617-921-1041
  • Fax: 617-323-8886
Mailing address:
  • Phone: 617-921-1041
  • Fax: 617-323-8886

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: MR. VADIM DANIEL BINDER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 617-921-1041