1396109195 NPI number — BANE COLONIAL, LLC

Table of content: (NPI 1396109195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396109195 NPI number — BANE COLONIAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANE COLONIAL, 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:
1396109195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 GRANITE ST STE 2203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAINTREE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02184-4963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-474-2263
Provider Business Mailing Address Fax Number:
781-871-3986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02188-2336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-337-3121
Provider Business Practice Location Address Fax Number:
781-337-9831
Provider Enumeration Date:
04/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BANE
Authorized Official First Name:
HARRISON
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
781-878-6700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 70012222205201 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110117821A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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