Provider Demographics
NPI:1629105382
Name:BASS RIVER DAY ACTIVITY PROGRAM, INC.
Entity Type:Organization
Organization Name:BASS RIVER DAY ACTIVITY PROGRAM, INC.
Other - Org Name:BASS RIVER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:POTVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-927-5326
Mailing Address - Street 1:437 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1311
Mailing Address - Country:US
Mailing Address - Phone:978-927-5326
Mailing Address - Fax:978-922-3109
Practice Address - Street 1:437 ESSEX ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1311
Practice Address - Country:US
Practice Address - Phone:978-927-5326
Practice Address - Fax:978-922-3109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1308548251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1319141Medicaid
MA1308548Medicaid