Provider Demographics
NPI:1063635399
Name:DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:MONSON DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C F O
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-624-7817
Mailing Address - Street 1:500 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2439
Mailing Address - Country:US
Mailing Address - Phone:617-624-7870
Mailing Address - Fax:
Practice Address - Street 1:MONSON DEV CNTR
Practice Address - Street 2:175 STATE AVE
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069
Practice Address - Country:US
Practice Address - Phone:413-283-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA916285Medicaid