Healthcare Provider Details

I. General information

NPI: 1528298296
Provider Name (Legal Business Name): MGH REVERE HEALTHCARE CENTRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OCEAN AVE
REVERE MA
02151-3675
US

IV. Provider business mailing address

190 MOUNTAIN AVE APT # 404
MALDEN MA
02148-2762
US

V. Phone/Fax

Practice location:
  • Phone: 781-485-6222
  • Fax: 781-485-6232
Mailing address:
  • Phone: 508-615-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number18434
License Number StateMA

VIII. Authorized Official

Name: RUCHITA VORA
Title or Position: STAFF PHYSICAL THERAPIST
Credential: PT, MSPT
Phone: 17814856222