Healthcare Provider Details

I. General information

NPI: 1194084392
Provider Name (Legal Business Name): WORCESTER ADULT DAYCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 GRAFTON ST
WORCESTER MA
01604-2647
US

IV. Provider business mailing address

1217 GRAFTON ST
WORCESTER MA
01604-2647
US

V. Phone/Fax

Practice location:
  • Phone: 617-823-3090
  • Fax:
Mailing address:
  • Phone: 617-823-3090
  • Fax:

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. BORIS SAPOZHNIKOV
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 617-823-3090