Basic Information
| Provider Information | |||||||||
| NPI: | 1619178431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROAD REACH OF CHATHAM INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROAD REACH OUTPATIENT REHAB - OT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 ORLEANS RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026501154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089454611 | ||||||||
| FaxNumber: | 5089452245 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 ORLEANS RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026501154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089454611 | ||||||||
| FaxNumber: | 5089452245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOGDANOVICH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5089454611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0884 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.