Provider Demographics
NPI:1942663851
Name:BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM, INC.
Entity Type:Organization
Organization Name:BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM, INC.
Other - Org Name:STACY KIRKPATRICK HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-654-1200
Mailing Address - Street 1:780 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2755
Mailing Address - Country:US
Mailing Address - Phone:857-654-1227
Mailing Address - Fax:857-654-1404
Practice Address - Street 1:461 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:857-654-1550
Practice Address - Fax:857-654-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4LQX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110020876QMedicaid