1275826372 NPI number — REM MEDICAL ARIZONA LLC

Table of content: (NPI 1275826372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275826372 NPI number — REM MEDICAL ARIZONA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REM MEDICAL ARIZONA 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:
Provider Other Organization Name Type Code:
6
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:
1275826372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
187 BALLARDVALE ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01887-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-774-7243
Provider Business Mailing Address Fax Number:
978-774-7421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5983 E GRANT RD
Provider Second Line Business Practice Location Address:
BUILDING 3, SUITE #105
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-2365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-318-1122
Provider Business Practice Location Address Fax Number:
520-318-1144
Provider Enumeration Date:
05/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VALENTINE
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
617-783-1441

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 635862 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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