1710048525 NPI number — 519 MAIN ST., INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710048525 NPI number — 519 MAIN ST., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
519 MAIN ST., 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:
THOMAS UPHAM HOUSE
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:
1710048525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 ACCESS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWOOD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02062-5237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-762-0703
Provider Business Mailing Address Fax Number:
781-762-2099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02052-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-359-6050
Provider Business Practice Location Address Fax Number:
508-359-7654
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THISSE
Authorized Official First Name:
PETER
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
781-762-0703

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0400 , 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: 0916986 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0692760001 . This is a "MEDICARE NSC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com