Basic Information
| Provider Information | |||||||||
| NPI: | 1376502070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | HARBOR COMMUNITY HEALTH CENTER-HYANNIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 MORTON STREET | ||||||||
| Address2: | |||||||||
| City: | MATTAPAN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021262834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175332300 | ||||||||
| FaxNumber: | 6175332301 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 ATTUCKS LN | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026011867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087780300 | ||||||||
| FaxNumber: | 5087788747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6175332300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HARBOR HEALTH SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QC1500X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 1301225 | 05 | MA | MEDICAID | 110027821A | 05 | MA | MEDICAID |