1255388732 NPI number — VISTACARE OF BOSTON LLC

Table of content: (NPI 1255388732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255388732 NPI number — VISTACARE OF BOSTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISTACARE OF BOSTON LLC
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:
KINDRED HOSPICE
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:
1255388732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 BRAWLEY SCHOOL RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-9601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-664-2876
Provider Business Mailing Address Fax Number:
704-664-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 HEMENWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01752-6751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-229-0912
Provider Business Practice Location Address Fax Number:
855-276-4473
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEBERG
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP OF LEGAL AND COMPLIANCE
Authorized Official Telephone Number:
704-664-2876

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110079500A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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