1831254408 NPI number — THEODORE I

Table of content: (NPI 1831254408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831254408 NPI number — THEODORE I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THEODORE I
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:
BOSTON HEALTH CARE SYSTEMS, INC.
Provider Other Organization Name Type Code:
4
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:
1831254408
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:
1865 OLD HUDSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55119-4308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-501-2378
Provider Business Mailing Address Fax Number:
651-738-1737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1314 LIVINGSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55118-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-501-2378
Provider Business Practice Location Address Fax Number:
651-738-1737
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOSTON
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
651-501-2378

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  802493-1-RMI , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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