1295734911 NPI number — 57 OLD ROAD TO NINE ACRE CORNER OPERATING COMPANY, LLC

Table of content: MS. CYNTHIA MARIE BROOKS OT (NPI 1881308039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295734911 NPI number — 57 OLD ROAD TO NINE ACRE CORNER OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
57 OLD ROAD TO NINE ACRE CORNER OPERATING COMPANY, 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:
1295734911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
57 OLD ROAD TO 9 ACRE CORNER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-371-3400
Provider Business Mailing Address Fax Number:
978-371-3406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 OLD ROAD TO 9 ACRE CORNER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-371-3400
Provider Business Practice Location Address Fax Number:
978-371-3406
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VAZQUEZ
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, SPECIAL PROJECTS
Authorized Official Telephone Number:
978-930-6051

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0983 , 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: 0926787 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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