1285685941 NPI number — EDITH NOURSE ROGERS MEMORIAL VAMC

Table of content: (NPI 1285685941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285685941 NPI number — EDITH NOURSE ROGERS MEMORIAL VAMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDITH NOURSE ROGERS MEMORIAL VAMC
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:
LYNN CBOC
Provider Other Organization Name Type Code:
4
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:
1285685941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 BACON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUGUS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01906-2405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
178-123-3463
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 BOSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01904-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
178-123-3463
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DES LOGES
Authorized Official First Name:
ANN
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
17816874923

Provider Taxonomy Codes

  • Taxonomy code: 284300000X , with the licence number:  138951 , 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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