Healthcare Provider Details

I. General information

NPI: 1609077429
Provider Name (Legal Business Name): BROAD REACH OF CHATHAM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 ORLEANS RD
NORTH CHATHAM MA
02650-1154
US

IV. Provider business mailing address

390 ORLEANS RD
NORTH CHATHAM MA
02650-1154
US

V. Phone/Fax

Practice location:
  • Phone: 508-945-4611
  • Fax: 508-945-2245
Mailing address:
  • Phone: 508-945-4611
  • Fax: 508-945-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0884
License Number StateMA

VIII. Authorized Official

Name: MR. WILLIAM BOGDANOVICH
Title or Position: DIRECTOR OF OPERATIONS
Credential: CNHA
Phone: 508-945-4611