Provider Demographics
NPI:1366626624
Name:SOUTH BOSTON COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH BOSTON COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AKINOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNGBADERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-269-7500
Mailing Address - Street 1:409 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2245
Mailing Address - Country:US
Mailing Address - Phone:617-269-7500
Mailing Address - Fax:617-464-7581
Practice Address - Street 1:409 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2245
Practice Address - Country:US
Practice Address - Phone:617-269-7500
Practice Address - Fax:617-464-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX10787OtherBLUE CROSS DENTAL