Provider Demographics
NPI:1053446484
Name:MARY IMMACULATE ADULT DAY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:MARY IMMACULATE ADULT DAY HEALTH CENTER, INC.
Other - Org Name:MI ADHC SATTE LITE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-685-6321
Mailing Address - Street 1:172 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-3849
Mailing Address - Country:US
Mailing Address - Phone:978-685-6321
Mailing Address - Fax:978-675-0050
Practice Address - Street 1:200 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1512
Practice Address - Country:US
Practice Address - Phone:978-685-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1903667Medicaid
MA6000235OtherEVERCARE