Provider Demographics
NPI:1003943515
Name:MCFADDEN MEMORIAL MANOR
Entity Type:Organization
Organization Name:MCFADDEN MEMORIAL MANOR
Other - Org Name:CITY OF MALDEN
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-322-1701
Mailing Address - Street 1:341 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-1604
Mailing Address - Country:US
Mailing Address - Phone:781-322-1700
Mailing Address - Fax:781-397-7375
Practice Address - Street 1:341 FOREST ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-1604
Practice Address - Country:US
Practice Address - Phone:781-322-1700
Practice Address - Fax:781-397-7375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0686313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0907731Medicaid