Provider Demographics
NPI:1508136177
Name:INTERIM HOUSE INC
Entity Type:Organization
Organization Name:INTERIM HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:MADARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:LADC1
Authorized Official - Phone:617-265-2636
Mailing Address - Street 1:62 WALDECK ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1329
Mailing Address - Country:US
Mailing Address - Phone:617-265-2636
Mailing Address - Fax:
Practice Address - Street 1:62 WALDECK ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1329
Practice Address - Country:US
Practice Address - Phone:617-265-2636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1697324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility