Provider Demographics
NPI:1326286378
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:SPRINGFIELD WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:780 CHESTNUT ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1637
Mailing Address - Country:US
Mailing Address - Phone:413-222-7711
Mailing Address - Fax:
Practice Address - Street 1:780 CHESTNUT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1637
Practice Address - Country:US
Practice Address - Phone:413-222-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty