1568771004 NPI number — ELDER SERVICES OF WORCESTER AREA, INC

Table of content: (NPI 1568771004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568771004 NPI number — ELDER SERVICES OF WORCESTER AREA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDER SERVICES OF WORCESTER AREA, INC
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:
Provider Other Organization Name Type Code:
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:
1568771004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 CHANDLER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01602-3339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-756-1545
Provider Business Mailing Address Fax Number:
508-754-7771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 CHANDLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01602-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-756-1545
Provider Business Practice Location Address Fax Number:
508-754-7771
Provider Enumeration Date:
10/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BALTRAMAITIS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
FISCAL MANAGER
Authorized Official Telephone Number:
508-756-1545

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1908863 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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