Provider Demographics
NPI:1629302112
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:WEST ROXBURY WELLNESS PAVILLION
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 1:1208B VFW PKWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4349
Mailing Address - Country:US
Mailing Address - Phone:617-477-8294
Mailing Address - Fax:617-477-8294
Practice Address - Street 1:1208B VFW PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4349
Practice Address - Country:US
Practice Address - Phone:617-477-8294
Practice Address - Fax:617-477-8294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVE MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty