Provider Demographics
NPI:1326368325
Name:CIRCLE OF LIFE MD LLC
Entity Type:Organization
Organization Name:CIRCLE OF LIFE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-468-2850
Mailing Address - Street 1:205 WILLOW ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-2255
Mailing Address - Country:US
Mailing Address - Phone:978-535-6043
Mailing Address - Fax:978-535-6047
Practice Address - Street 1:203 WILLOW ST BLDG B
Practice Address - Street 2:
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-2292
Practice Address - Country:US
Practice Address - Phone:978-535-6043
Practice Address - Fax:978-535-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA223761OtherLICENSE