1588200166 NPI number — SRC BLACKSTONE OP, LLC

Table of content: (NPI 1588200166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588200166 NPI number — SRC BLACKSTONE OP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SRC BLACKSTONE OP, 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:
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:
1588200166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O WINGATE HEALTHCARE, INC.
Provider Second Line Business Mailing Address:
63 KENDRICK STREET
Provider Business Mailing Address City Name:
NEEDHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-707-9000
Provider Business Mailing Address Fax Number:
781-281-8827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 BLACKSTONE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02906-4936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-273-6565
Provider Business Practice Location Address Fax Number:
401-273-6568
Provider Enumeration Date:
11/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SCHARF
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL COUNSEL
Authorized Official Telephone Number:
781-707-9030

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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