Provider Demographics
NPI:1669924783
Name:COMMONWEALTH CARE ALLIANCE
Entity type:Organization
Organization Name:COMMONWEALTH CARE ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-600-3195
Mailing Address - Street 1:529 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:529 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1125
Practice Address - Country:US
Practice Address - Phone:617-600-3195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization