1699119826 NPI number — MISS CARISSA LYNNE SURACE

Table of content: MISS CARISSA LYNNE SURACE (NPI 1699119826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699119826 NPI number — MISS CARISSA LYNNE SURACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURACE
Provider First Name:
CARISSA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1699119826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
APT 1
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-3525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-953-8155
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 REDFIELD ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
DORCHESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02122-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-288-7450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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