1972677326 NPI number — NATICK SPORTS AND RACQUET CLUB

Table of content: (NPI 1972677326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972677326 NPI number — NATICK SPORTS AND RACQUET CLUB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATICK SPORTS AND RACQUET CLUB
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:
1972677326
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:
203 OAK ST
Provider Second Line Business Mailing Address:
LONGFELLOW SPORTS CLUB
Provider Business Mailing Address City Name:
NATICK
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01760-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-653-4633
Provider Business Mailing Address Fax Number:
508-650-4986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 OAK ST
Provider Second Line Business Practice Location Address:
LONGFELLOW SPORTS CLUB
Provider Business Practice Location Address City Name:
NATICK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01760-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-653-4633
Provider Business Practice Location Address Fax Number:
508-650-4986
Provider Enumeration Date:
11/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLLEY
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIETITIAN
Authorized Official Telephone Number:
508-653-4633

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  LDN1011 , 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: 6300209 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5582051 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 39410 . This is a "HARVARD PILGRIM HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 763282 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: LD0022 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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