1225010192 NPI number — BASS RIVER HEALTHCARE ASSOCIATES, INC.

Table of content: (NPI 1225010192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225010192 NPI number — BASS RIVER HEALTHCARE ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASS RIVER HEALTHCARE ASSOCIATES, INC.
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:
1225010192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 MAIN ST
Provider Second Line Business Mailing Address:
ROUTE 28
Provider Business Mailing Address City Name:
S YARMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02664-5254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-394-1353
Provider Business Mailing Address Fax Number:
508-398-2866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 MAIN ST
Provider Second Line Business Practice Location Address:
ROUTE 28
Provider Business Practice Location Address City Name:
S YARMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02664-5254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-394-1353
Provider Business Practice Location Address Fax Number:
508-398-2866
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REIDA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-394-1353

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  276 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Y39057 . This is a "BCBS MA CHIRO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y31273 . This is a "BCBS MA PT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA56061 . This is a "HPHC PT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 35260 . This is a "HPHC CHIRO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9783199 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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