1528066990 NPI number — ALLIANCE HEALTH OF BROCKTON, INC.

Table of content: (NPI 1528066990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528066990 NPI number — ALLIANCE HEALTH OF BROCKTON, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIANCE HEALTH OF BROCKTON, 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:
ALLIANCE HEALTH AT WEST ACRES
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:
1528066990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 PLEASANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-583-6000
Provider Business Mailing Address Fax Number:
508-580-2468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-3055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-583-6000
Provider Business Practice Location Address Fax Number:
508-580-2468
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KEMP
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
774-348-2001

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0925594 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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