Provider Demographics
NPI:1295275311
Name:RALPH AMBROISE
Entity type:Organization
Organization Name:RALPH AMBROISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROISE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:617-312-1961
Mailing Address - Street 1:164 RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-4033
Mailing Address - Country:US
Mailing Address - Phone:617-312-1961
Mailing Address - Fax:
Practice Address - Street 1:164 RIVERVIEW ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-4033
Practice Address - Country:US
Practice Address - Phone:617-312-1961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN66605164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty