1780842211 NPI number — MS. GWENDOLYN CAROLINE MCLEAN LIC AC

Table of content: MS. GWENDOLYN CAROLINE MCLEAN LIC AC (NPI 1780842211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780842211 NPI number — MS. GWENDOLYN CAROLINE MCLEAN LIC AC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCLEAN
Provider First Name:
GWENDOLYN
Provider Middle Name:
CAROLINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LIC AC
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:
1780842211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 ELM ST
Provider Second Line Business Mailing Address:
UNIT 2
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-803-5636
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MAIN ST
Provider Second Line Business Practice Location Address:
FOREVER YOUNG SKIN CARE AND MEDICAL DAY SPA
Provider Business Practice Location Address City Name:
MELROSE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02176-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-665-3080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2008

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: 171100000X , with the licence number:  227943 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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