Basic Information
| Provider Information | |||||||||
| NPI: | 1487806725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST BOSTON NEIGHBORHOOD HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 STURGIS ST | ||||||||
| Address2: | |||||||||
| City: | WINTHROP | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021521219 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 STURGIS ST | ||||||||
| Address2: | |||||||||
| City: | WINTHROP | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021521219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175695800 | ||||||||
| FaxNumber: | 6175684756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2008 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILMOT | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP/CHIEF OPERATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175684714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 57249 | MA | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 57249 | 01 | MA | MA CONTROLLED SUBSTANCE | OTHER | FE1121122 | 01 | DEA | OTHER |