Provider Demographics
NPI:1538609904
Name:ELM TREE CLINIC, LLC
Entity type:Organization
Organization Name:ELM TREE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:V
Authorized Official - Last Name:TOROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-354-3555
Mailing Address - Street 1:11 DEXTER AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4105
Mailing Address - Country:US
Mailing Address - Phone:617-354-3555
Mailing Address - Fax:617-481-4655
Practice Address - Street 1:12 WOOD ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-1532
Practice Address - Country:US
Practice Address - Phone:617-354-3555
Practice Address - Fax:617-481-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty