1811021090 NPI number — MASSACHUSETTS MENTOR LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811021090 NPI number — MASSACHUSETTS MENTOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASSACHUSETTS MENTOR LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811021090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 BRIDGE ST
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
DEDHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02026-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-326-4207
Provider Business Mailing Address Fax Number:
781-326-4654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 BRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
DEDHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02026-1759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-326-4207
Provider Business Practice Location Address Fax Number:
781-326-4654
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
DAIVD
Authorized Official Middle Name:
C
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
781-326-4207

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  1615 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1904469 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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