Provider Demographics
NPI:1447574710
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:MALDEN WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:388 PLEASANT ST
Mailing Address - Street 2:STE 305
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-8143
Mailing Address - Country:US
Mailing Address - Phone:781-333-5467
Mailing Address - Fax:781-333-5465
Practice Address - Street 1:388 PLEASANT ST
Practice Address - Street 2:STE 305
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8143
Practice Address - Country:US
Practice Address - Phone:781-333-5467
Practice Address - Fax:781-333-5465
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVE MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-16
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty