Basic Information
Provider Information | |||||||||
NPI: | 1346391224 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROCKTON NEIGHBORHOOD HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 231 MAIN ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023014342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5085591567 | ||||||||
FaxNumber: | 5085595073 | ||||||||
Practice Location | |||||||||
Address1: | 157 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023014012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5085596699 | ||||||||
FaxNumber: | 5084276374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AKEKE | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
AuthorizedOfficialTelephone: | 5085596699 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X |   |   | Y |   | Managed Care Organizations | Health Maintenance Organization |   |
No ID Information.