Healthcare Provider Details

I. General information

NPI: 1902169105
Provider Name (Legal Business Name): 411 WAVERLY OAKS RD, SUITE#214, WALTHAM, MA 02452
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 WAVERLY OAKS RD
WALTHAM MA
02452-8448
US

IV. Provider business mailing address

411 WAVERLY OAKS RD STE 214
WALTHAM MA
02452-8437
US

V. Phone/Fax

Practice location:
  • Phone: 617-513-2158
  • Fax: 617-206-3195
Mailing address:
  • Phone: 617-513-2158
  • Fax: 617-206-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. WOLF GAFANOVICH
Title or Position: CLINICAL DIRECTOR
Credential: RN
Phone: 617-513-2158