Healthcare Provider Details

I. General information

NPI: 1629302112
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208B VFW PKWY SUITE 305
WEST ROXBURY MA
02132-4349
US

IV. Provider business mailing address

1208B VFW PKWY SUITE 305
WEST ROXBURY MA
02132-4349
US

V. Phone/Fax

Practice location:
  • Phone: 617-477-8294
  • Fax: 617-477-8294
Mailing address:
  • Phone: 617-477-8294
  • Fax: 617-477-8294

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: MS. MARY J DELONG
Title or Position: CREDENTIALING MANAGER
Credential: MM,RHIA
Phone: 413-222-7711