Provider Demographics
NPI:1396079414
Name:GAVIN FOUNDATION
Entity type:Organization
Organization Name:GAVIN FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC I
Authorized Official - Phone:617-268-5517
Mailing Address - Street 1:675 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-3063
Mailing Address - Country:US
Mailing Address - Phone:617-268-5517
Mailing Address - Fax:617-269-3296
Practice Address - Street 1:49 L ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1511
Practice Address - Country:US
Practice Address - Phone:617-268-5000
Practice Address - Fax:617-268-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0853261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center