Healthcare Provider Details

I. General information

NPI: 1194949073
Provider Name (Legal Business Name): VINEYARD HEALTHCARE ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 STATE RD STE 13
VINEYARD HAVEN MA
02568-5621
US

IV. Provider business mailing address

59 TEMPLE PL STE 662
BOSTON MA
02111-1307
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-3900
  • Fax: 508-693-0444
Mailing address:
  • Phone: 617-447-2146
  • Fax: 617-259-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS CHERYL A CHURCH
Title or Position: OFFICE MANAGER
Credential:
Phone: 617-447-2146