Provider Demographics
NPI:1396771820
Name:DOUGLAS A. THOM CLINIC, INC.
Entity type:Organization
Organization Name:DOUGLAS A. THOM CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:ROWE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-655-5222
Mailing Address - Street 1:251 W CENTRAL ST
Mailing Address - Street 2:SUITE 22
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-3758
Mailing Address - Country:US
Mailing Address - Phone:508-655-5222
Mailing Address - Fax:508-655-9737
Practice Address - Street 1:126 PHOENIX AVE
Practice Address - Street 2:BUILDING #2
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4931
Practice Address - Country:US
Practice Address - Phone:978-453-8331
Practice Address - Fax:978-453-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA008838261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803301Medicaid
MA1802097Medicaid
MA1887289Medicaid
MA1887271Medicaid
MA1803131Medicaid
MA1800353Medicaid
MA1800574Medicaid
MA1802976Medicaid