1407884059 NPI number — THE COMMONWEALTH OF MASSACHUSETTS

Table of content: (NPI 1407884059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407884059 NPI number — THE COMMONWEALTH OF MASSACHUSETTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE COMMONWEALTH OF MASSACHUSETTS
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:
QUINCY MENTAL HEALTH CENTER
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:
1407884059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
167 LYMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01581-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-616-3500
Provider Business Mailing Address Fax Number:
508-616-2859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 QUINCY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02169-8130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-626-9002
Provider Business Practice Location Address Fax Number:
617-770-2953
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WING
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
NE/SUBURBAN AREA DIRECTOR
Authorized Official Telephone Number:
508-616-3500

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1102699 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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