| NPI |
1730654070 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Entity Type Code |
2 |
The last name of the provider. If the provider is an individual, this is the legal name. |
| Employer Identification Number EIN |
|
The first name of the provider, if the provider
is an individual. |
| Provider Organization Name Legal Business Name |
CASA ESPERANZA, INC. |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Practice Location Address |
291 EUSTIS ST |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
ROXBURY |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
| Provider Business Practice Location Address State Name |
MA |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
021192826 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
6174451123 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
10/12/2018 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
10/12/2018 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
JACKSON |
The telephone number associated with the location address of the provider being identified. |
| Authorized Official First Name |
EVA |
The first name of the authorized official. |
| Authorized Official Title or Position |
DIRECTOR REVENUE CYCLE MANAGEMENT |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Authorized Official Telephone Number |
6178225594 |
The date that a record was last updated or changed. |
| Healthcare Provider Taxonomy Code 1 |
261QM0850X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Other Provider Identifier 1 |
04298 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
01 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Other Provider Identifier State 1 |
MA |
|
| Other Provider Identifier Issuer 1 |
TUFTS HEALTH PLAN |
|
| Other Provider Identifier 2 |
110082430B |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 2 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 2 |
MA |
|
| Other Provider Identifier 3 |
43324 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 3 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 3 |
MA |
|
| Other Provider Identifier Issuer 3 |
BEACON HEALTH STRATEGIES |
|
| Other Provider Identifier 4 |
43304 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 4 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 4 |
MA |
|
| Other Provider Identifier Issuer 4 |
BEACON MBHP VALUE OPTION |
|
| Is Organization Subpart |
Y |
|
| Parent Organization LBN |
CASA ESPERANZA, INC. |
|
| Parent Organization TIN |
|
|