1164039152 NPI number — ADVANTAGE SURGICAL AND WOUND CARE MASSACHUSETTS PC

Table of content: (NPI 1164039152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164039152 NPI number — ADVANTAGE SURGICAL AND WOUND CARE MASSACHUSETTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE SURGICAL AND WOUND CARE MASSACHUSETTS PC
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:
1164039152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 N PACIFIC COAST HWY STE 2175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL SEGUNDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90245-5639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-878-3289
Provider Business Mailing Address Fax Number:
877-817-3227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 PROCTOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REVERE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02151-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-878-3289
Provider Business Practice Location Address Fax Number:
877-817-3227
Provider Enumeration Date:
09/24/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
877-878-3289

Provider Taxonomy Codes

  • Taxonomy code: 207PE0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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