Basic Information
| Provider Information | |||||||||
| NPI: | 1841271087 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROAD REACH HOSPICE & PALLIATIVE CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 ORLEANS ROAD | ||||||||
| Address2: | |||||||||
| City: | NO CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089454611 | ||||||||
| FaxNumber: | 5089454608 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 ORLEANS RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHATHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026501154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089451611 | ||||||||
| FaxNumber: | 5089452245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2005 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOGDANOVICH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5089454611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CNHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | MA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0600121 | 05 | MA | MEDICAID | 110024151A | 05 | MA | MEDICAID |