=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104504760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOSTON HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2023
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 253 PLEASANT LAKE AVE
-----------------------------------------------------
City | HARWICH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02645-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-785-2066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 TRUMAN RD
-----------------------------------------------------
City | NEWTON CENTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02459-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-337-8051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | QIANG NAI
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 617-785-2066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------