Provider Demographics
NPI:1326155458
Name:THE COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:THE COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:BROCKTON MULTI SERVICE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-297-3246
Mailing Address - Street 1:165 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2988
Mailing Address - Country:US
Mailing Address - Phone:508-897-2069
Mailing Address - Fax:
Practice Address - Street 1:165 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2988
Practice Address - Country:US
Practice Address - Phone:508-897-2069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QM0801X
333600000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305565Medicaid
2155167OtherPK
MA1305565Medicaid