1689090862 NPI number — ODONATA PSYCHOTHERAPY & RETREAT CENTER LLC

Table of content: (NPI 1689090862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689090862 NPI number — ODONATA PSYCHOTHERAPY & RETREAT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ODONATA PSYCHOTHERAPY & RETREAT CENTER 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:
1689090862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 PINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORESTDALE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02644-1413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
774-247-4939
Provider Business Mailing Address Fax Number:
774-302-4419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUZZARDS BAY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
774-247-4939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WILEY
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
774-247-4939

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110101319A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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