Provider Demographics
NPI:1902073497
Name:POLYCLINIC LLC
Entity Type:Organization
Organization Name:POLYCLINIC LLC
Other - Org Name:AGINGWELL ADULT DAY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:IZABELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DASHEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-485-7700
Mailing Address - Street 1:420 MAPLE ST
Mailing Address - Street 2:SUITE 25
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-6202
Mailing Address - Country:US
Mailing Address - Phone:508-485-7700
Mailing Address - Fax:
Practice Address - Street 1:420 MAPLE ST
Practice Address - Street 2:SUITE 25
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-6202
Practice Address - Country:US
Practice Address - Phone:508-485-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1906950Medicaid