Provider Demographics
NPI:1447237185
Name:MOODY STREET TOTAL HEALTH, INC.
Entity Type:Organization
Organization Name:MOODY STREET TOTAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ST.LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-821-7054
Mailing Address - Street 1:3 COMMON STREET #2
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451
Mailing Address - Country:US
Mailing Address - Phone:978-821-7054
Mailing Address - Fax:774-208-0712
Practice Address - Street 1:3 COMMON STREET #2
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:978-821-7054
Practice Address - Fax:774-208-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA798431OtherTUFTS HEALTH PLAN
MA974044OtherNETWORK HEALTH PLAN
MA033487192OtherHCVM
MA1612913Medicaid
MAY36596OtherBC/BS OF MA INDIVIDUAL ID
MAY39835OtherBC/BS OF MA GROUP ID
MA1867401004OtherCIGNA HEALTH CARE
MA2859278OtherAETNA/US HEALTHCARE
MA4404288OtherUNITED HEALTH CARE
MA9228734OtherPHCS
MA27243OtherNEIGHBORHOOD HEALTH PLAN
MA351902OtherHARVARD PILGRIM
MA1867401004OtherCIGNA HEALTH CARE
MA27243OtherNEIGHBORHOOD HEALTH PLAN
MA1612913Medicaid