1972924371 NPI number — INTENTIONAL SELF. LLC

Table of content: (NPI 1972924371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972924371 NPI number — INTENTIONAL SELF. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTENTIONAL SELF. 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:
1972924371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 MEMORIAL PKWY
Provider Second Line Business Mailing Address:
PMB 211
Provider Business Mailing Address City Name:
RANDOLPH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02368-4511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-767-0008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 CABOT PL
Provider Second Line Business Practice Location Address:
SUITE # 6
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02072-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-767-0008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RANGE
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
781-767-0008

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  5509 , 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)