Provider Information for 1912135666
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GLEN T PROSPERE
Sex: Male
NPI: 1912135666
Last Updated: 2009-07-06
Certification Date:
Certification Date:
Details
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NPI | 1912135666 | ||||||||
Enumeration Date | 2009-07-01 | ||||||||
NPI Type | NPI-1 Individual | ||||||||
Sole Proprietor | NO | ||||||||
Status | Active | ||||||||
Mailing Address | 43 PIERCE STREET HYDE PARK, MA 02136 United States Phone: 617-364-9464 | Fax: | ||||||||
Primary Practice Address | 1601 WASHINGTON STREET BOSTON, MA 02118-1951 United States Phone: 617-425-2000 | Fax:617-424-8725 | ||||||||
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