Healthcare Provider Details

I. General information

NPI: 1811321417
Provider Name (Legal Business Name): NO BUSINESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 ADAMS ST APT#2
WALTHAM MA
02453-3910
US

IV. Provider business mailing address

172 ADAMS ST APT#2
WALTHAM MA
02453-3910
US

V. Phone/Fax

Practice location:
  • Phone: 781-526-6522
  • Fax:
Mailing address:
  • Phone: 781-526-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberRN236191
License Number StateMA

VIII. Authorized Official

Name: MRS. LAURETTE THEODULE JOSEPH
Title or Position: RN
Credential: RN
Phone: 781-526-6522