Healthcare Provider Details

I. General information

NPI: 1598078172
Provider Name (Legal Business Name): COMMUNITY ADULT DAYCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BROADWAY
LAWRENCE MA
01840-1014
US

IV. Provider business mailing address

120 BROADWAY
LAWRENCE MA
01840-1014
US

V. Phone/Fax

Practice location:
  • Phone: 508-294-8756
  • Fax: 617-507-7931
Mailing address:
  • Phone: 508-294-8756
  • Fax: 617-507-7931

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: SERGEY BOLOGOV
Title or Position: MEMBER
Credential:
Phone: 617-285-2227