Provider Demographics
NPI:1104017961
Name:DODGE PARK LLC
Entity Type:Organization
Organization Name:DODGE PARK LLC
Other - Org Name:DODGE PARK REST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-571-8972
Mailing Address - Street 1:101 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2463
Mailing Address - Country:US
Mailing Address - Phone:508-853-8180
Mailing Address - Fax:508-853-4545
Practice Address - Street 1:101 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2463
Practice Address - Country:US
Practice Address - Phone:508-853-8180
Practice Address - Fax:508-853-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1318311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home