Provider Demographics
NPI:1922076447
Name:BOSTON CLINICAL LABORATORY
Entity Type:Organization
Organization Name:BOSTON CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-255-0555
Mailing Address - Street 1:100 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5030
Mailing Address - Country:US
Mailing Address - Phone:781-255-0555
Mailing Address - Fax:781-255-0594
Practice Address - Street 1:100 RIVER RIDGE DR
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5030
Practice Address - Country:US
Practice Address - Phone:781-255-0555
Practice Address - Fax:781-255-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0805912Medicaid
MA0805912Medicaid