Provider Demographics
NPI:1255630448
Name:GREATER LAWRENCE FAMILY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:GREATER LAWRENCE FAMILY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-689-6683
Mailing Address - Street 1:57 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1144
Mailing Address - Country:US
Mailing Address - Phone:978-686-8521
Mailing Address - Fax:978-686-8594
Practice Address - Street 1:57 RIVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-1144
Practice Address - Country:US
Practice Address - Phone:978-686-8521
Practice Address - Fax:978-686-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4943261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303775Medicaid