Basic Information
| Provider Information | |||||||||
| NPI: | 1114054988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST BOSTON NEIGHBORHOOD HEALTH CENTER-NEIGHBORHOOD PACE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ESP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GOVE ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021281920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6715695800 | ||||||||
| FaxNumber: | 6175684756 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GOVE ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021281920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILMOT | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP/CHIEF OPERATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175684714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | 1802542 | MA | Y | Agencies | PACE Provider Organization |
No ID Information.