Basic Information
| Provider Information | |||||||||
| NPI: | 1366626624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH BOSTON COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021272245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172697500 | ||||||||
| FaxNumber: | 6174647581 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021272245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172697500 | ||||||||
| FaxNumber: | 6174647581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2007 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | OGUNGBADERO | ||||||||
| AuthorizedOfficialFirstName: | AKINOLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6172697500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | X10787 | 01 | MA | BLUE CROSS DENTAL | OTHER |