1659416980 NPI number — NORTHEAST SENIOR HEALTH CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659416980 NPI number — NORTHEAST SENIOR HEALTH CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST SENIOR HEALTH CORP
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:
1659416980
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:
800 CUMMINGS CTR
Provider Second Line Business Mailing Address:
SUITE 266U
Provider Business Mailing Address City Name:
BEVERLY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01915-6175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-921-1697
Provider Business Mailing Address Fax Number:
978-921-1624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 CUMMINGS CTR
Provider Second Line Business Practice Location Address:
SUITE 266U
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-6175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-921-1697
Provider Business Practice Location Address Fax Number:
978-921-1624
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLENDON
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
LIFELINE PROGRAM MANAGER
Authorized Official Telephone Number:
978-921-1697

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1532316 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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