Healthcare Provider Details

I. General information

NPI: 1093856965
Provider Name (Legal Business Name): THE COMMONWEALTH OF MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SOUTH ST
JAMAICA PLAIN MA
02130-3515
US

IV. Provider business mailing address

305 SOUTH ST
JAMAICA PLAIN MA
02130-3515
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-6675
  • Fax: 857-323-8352
Mailing address:
  • Phone: 617-983-6201
  • Fax: 857-323-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW COURCHENE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 617-624-5309