Basic Information
| Provider Information | |||||||||
| NPI: | 1255949327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST BOSTON NEIGHBORHOOD HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 MAVERICK SQ | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021282335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684756 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MAVERICK SQ | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021282335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZARD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6175687244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 110022129H | 05 | MA | MEDICAID |