Provider Demographics
NPI:1629355847
Name:GREATER WALTHAM ARC, INC.
Entity Type:Organization
Organization Name:GREATER WALTHAM ARC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WISWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-899-1344
Mailing Address - Street 1:56 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-4433
Mailing Address - Country:US
Mailing Address - Phone:781-899-1344
Mailing Address - Fax:781-899-2197
Practice Address - Street 1:56 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-4433
Practice Address - Country:US
Practice Address - Phone:781-899-1344
Practice Address - Fax:781-899-2197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER WALTHAM ARC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027946DMedicaid