=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104070564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH LINK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2008
-----------------------------------------------------
Last Update Date | 11/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 JACQUES AVE
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01610-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-860-1247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1053 PLEASANT ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01602-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-757-5852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MARILYN O'NEIL TORMEY
-----------------------------------------------------
Credential | NP PHD
-----------------------------------------------------
Telephone | 508-860-1077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 133984
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------