Basic Information
| Provider Information | |||||||||
| NPI: | 1184377343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYSTIC VALLEY MASS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 MAIN ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017203301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783717010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 92 MONTVALE AVE STE 3000 | ||||||||
| Address2: | |||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021803658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814386350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2022 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOOS | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7837170109 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MYSTIC VALLEY DERMATOLOGY ASSOCIATES, P.C. | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.