Provider Demographics
NPI:1902169105
Name:411 WAVERLY OAKS RD, SUITE#214, WALTHAM, MA 02452
Entity Type:Organization
Organization Name:411 WAVERLY OAKS RD, SUITE#214, WALTHAM, MA 02452
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WOLF
Authorized Official - Middle Name:
Authorized Official - Last Name:GAFANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:617-513-2158
Mailing Address - Street 1:411 WAVERLY OAKS RD STE 214
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8437
Mailing Address - Country:US
Mailing Address - Phone:617-513-2158
Mailing Address - Fax:617-206-3195
Practice Address - Street 1:411 WAVERLY OAKS RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:617-513-2158
Practice Address - Fax:617-206-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care