Healthcare Provider Details

I. General information

NPI: 1497574206
Provider Name (Legal Business Name): OLD COLONY YMCA WELLNESS SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 CENTRAL ST
STOUGHTON MA
02072-1900
US

IV. Provider business mailing address

320 MAIN ST
BROCKTON MA
02301-5340
US

V. Phone/Fax

Practice location:
  • Phone: 781-341-2016
  • Fax:
Mailing address:
  • Phone: 508-583-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES CLIFFORD
Title or Position: PRESIDENT & CEO
Credential:
Phone: 508-897-1220