Healthcare Provider Details

I. General information

NPI: 1730514399
Provider Name (Legal Business Name): SHELBURNE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MOHAWK TRL
SHELBURNE FALLS MA
01370-9705
US

IV. Provider business mailing address

1000 MOHAWK TRL
SHELBURNE FALLS MA
01370-9705
US

V. Phone/Fax

Practice location:
  • Phone: 413-625-6021
  • Fax: 413-625-6073
Mailing address:
  • Phone: 413-625-6021
  • Fax: 413-625-6073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number51476
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberRN181085
License Number StateMA

VIII. Authorized Official

Name: ANNA C FOSTER
Title or Position: FNP
Credential: FNP
Phone: 413-625-6021