Provider Demographics
NPI:1255388732
Name:VISTACARE OF BOSTON LLC
Entity type:Organization
Organization Name:VISTACARE OF BOSTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP OF LEGAL AND COMPLIANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9601
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:406 HEMENWAY ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-6751
Practice Address - Country:US
Practice Address - Phone:508-229-0912
Practice Address - Fax:855-276-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110079500AMedicaid
221574Medicare Oscar/Certification