1750504064 NPI number — DEPARTMENT OF DEVELOPMENTAL SERVICES

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 1750504064 NPI number — DEPARTMENT OF DEVELOPMENTAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF DEVELOPMENTAL SERVICES
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:
SOUTH VALLEY AREA OFFICE CM
Provider Other Organization Name Type Code:
3
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:
1750504064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 HARRISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-624-7870
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SO VALLEY CM
Provider Second Line Business Practice Location Address:
79 NOTHE ST STE 2
Provider Business Practice Location Address City Name:
SOUTHBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-764-5304
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAILLET
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
C F O
Authorized Official Telephone Number:
617-624-7814

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1813242 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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