Basic Information
| Provider Information | |||||||||
| NPI: | 1699785543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRECIWILK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013020910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137728500 | ||||||||
| FaxNumber: | 4137728900 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 MONTAGUE CITY ROAD | ||||||||
| Address2: | FARREN CARE CENTER | ||||||||
| City: | TURNERS FALLS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137743111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 128700 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP0608 | 01 | MA | BC/BS MA | OTHER | 0312240 | 05 | MA | MEDICAID | 25339 | 01 | MA | BMC HEALTHNET | OTHER |