Healthcare Provider Details

I. General information

NPI: 1417919010
Provider Name (Legal Business Name): FAMILY CARE EXTENDED, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 HIGHLAND AVE
NEEDHAM MA
02494-2232
US

IV. Provider business mailing address

687 HIGHLAND AVE
NEEDHAM MA
02494-2232
US

V. Phone/Fax

Practice location:
  • Phone: 781-449-5155
  • Fax:
Mailing address:
  • Phone: 781-449-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0611247
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MR. ANATOLIY S RIVKIN
Title or Position: VP
Credential:
Phone: 781-449-5155