Provider Demographics
NPI:1245609064
Name:EISA, MOHAMMED
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:EISA
Suffix:
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 1:759 BENNINGTON ST
Mailing Address - Street 2:1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1133
Mailing Address - Country:US
Mailing Address - Phone:804-873-6581
Mailing Address - Fax:
Practice Address - Street 1:759 BENNINGTON ST
Practice Address - Street 2:1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1133
Practice Address - Country:US
Practice Address - Phone:804-873-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities