1225067481 NPI number — NORTHEAST HEALTH SERVICES, LLC

Table of content: (NPI 1225067481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225067481 NPI number — NORTHEAST HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST HEALTH SERVICES, 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:
(DBA): ATTLEBORO BEHAVIORAL HEALTH CENTER/CAPE BEHAVIORAL HEALTH CENTE
Provider Other Organization Name Type Code:
5
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:
1225067481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39A INDUSTRIAL PARK ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-4868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-830-1444
Provider Business Mailing Address Fax Number:
508-830-3655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 TAUNTON GREEN
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
TAUNTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02780-3243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-880-6666
Provider Business Practice Location Address Fax Number:
508-880-6655
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VARONKO
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
508-830-1444

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  4570 AND 4984 , 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)

  • Identifier: 1311778 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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