Provider Demographics
NPI:1205604733
Name:THE LIVING TREE
Entity type:Organization
Organization Name:THE LIVING TREE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:978-906-1254
Mailing Address - Street 1:58 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331
Mailing Address - Country:US
Mailing Address - Phone:978-906-1254
Mailing Address - Fax:
Practice Address - Street 1:2270 MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331
Practice Address - Country:US
Practice Address - Phone:978-906-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center