Healthcare Provider Details

I. General information

NPI: 1487040390
Provider Name (Legal Business Name): IMMACULA ELDERLY CARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 OTIS ST
MEDFORD MA
02155-4017
US

IV. Provider business mailing address

26 COLUMBIA RD
MEDFORD MA
02155-4507
US

V. Phone/Fax

Practice location:
  • Phone: 857-266-5345
  • Fax:
Mailing address:
  • Phone: 857-266-5345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. RONALD PIERRE
Title or Position: PASTOR
Credential:
Phone: 781-391-1002