MEDICARE: GAVIN FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	0853	MA

General Provider Information

NPI Number	:	1396079414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAVIN FOUNDATION

Provider Business Mailing Address
First Line	:	675 E 4TH ST
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-3063
Country	:	US
Telephone Number	:	617-268-5517
Fax Number	:	617-269-3296

Provider Business Practice Location Address
First Line	:	49 L ST
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-1511
Country	:	US
Telephone Number	:	617-268-5000
Fax Number	:	617-268-5008

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. JOHN MCGAHAN
Credential	:	LADC I
Telephone Number	:	617-268-5517

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	09/22/2009

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Directions to “GAVIN FOUNDATION ” Practice Location

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