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General NPI Number Information
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NPI Number | 1134490329
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Entity Type | Organization
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Legal Business Name | MATCH COMMUNITY DAY CHARTER PUBLIC SCHOOL
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Dates
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Enumeration Date | 01/19/2012
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Last Update Date | 01/19/2012
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Provider Practice Location Address
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Address Line | 215 FOREST HILLS ST
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City | JAMAICA PLAIN
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State | MA
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Zip | 02130-3302
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Country | US
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Telephone | 857-203-9666
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 COMMONWEALTH AVE
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City | BOSTON
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State | MA
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Zip | 02215-1308
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Country | US
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Telephone | 617-232-0300
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Fax | 617-232-2838
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. MIKE LARSSON
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Credential |
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Telephone | 781-956-3706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251300000X
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Taxonomy Name | Local Education Agency (LEA)
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License Number | 04650105
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License Number State | MA
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