Basic Information
| Provider Information | |||||||||
| NPI: | 1720081912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTHAS VINEYARD COMMUNITY SERVICES, INC DBA VISITING NURSE SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
| FaxNumber: | 5086936669 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 EDGARTOWN VINEYARD HAVEN ROAD | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
| FaxNumber: | 5086936669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS | ||||||||
| AuthorizedOfficialFirstName: | JULIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5086937900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 005601 | MA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 120125 | 01 | MA | BLUE CROSS | OTHER | 0601845 | 05 | MA | MEDICAID | 704411 | 01 | MA | HARVARD PILGRIM HEALTH CA | OTHER |