Basic Information
| Provider Information | |||||||||
| NPI: | 1386740538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTONVA HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 BELMONT ST | ||||||||
| Address2: | 11PC | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015596 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 BELMONT ST | ||||||||
| Address2: | 11PC | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085834500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRABER | ||||||||
| AuthorizedOfficialFirstName: | MARCIA | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 5085834500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 143788 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.