Provider Demographics
NPI:1174837033
Name:REVERE ADULT DAY HEALTH CARE
Entity Type:Organization
Organization Name:REVERE ADULT DAY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VINOKUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-370-4714
Mailing Address - Street 1:765 REVERE BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5318
Mailing Address - Country:US
Mailing Address - Phone:301-370-4714
Mailing Address - Fax:301-560-8270
Practice Address - Street 1:765 REVERE BEACH PKWY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5318
Practice Address - Country:US
Practice Address - Phone:301-370-4714
Practice Address - Fax:301-560-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========Medicaid