Provider Demographics
NPI:1073088407
Name:WEBSTER, LUIS ALONSO SR
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALONSO
Last Name:WEBSTER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200751
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-0013
Mailing Address - Country:US
Mailing Address - Phone:617-959-1332
Mailing Address - Fax:617-516-8934
Practice Address - Street 1:120 SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2650
Practice Address - Country:US
Practice Address - Phone:617-964-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA474883763374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty