1104946862 NPI number — KLS MANAGEMENT

Table of content: (NPI 1104946862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104946862 NPI number — KLS MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KLS MANAGEMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EAST COAST DIAGNOSTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104946862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1842 BEACON ST
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
BROOKLINE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02445-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-739-1300
Provider Business Mailing Address Fax Number:
617-739-5967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1842 BEACON ST
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02445-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-739-1300
Provider Business Practice Location Address Fax Number:
617-739-5967
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
617-739-1300

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9780661 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00191969 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5845531 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 974285 . This is a "NETWORKHEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 611868 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 034469 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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