Provider Demographics
NPI:1639337280
Name:PINE STREET INN, INC.
Entity Type:Organization
Organization Name:PINE STREET INN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-892-9116
Mailing Address - Street 1:444 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2404
Mailing Address - Country:US
Mailing Address - Phone:617-482-4944
Mailing Address - Fax:617-451-1890
Practice Address - Street 1:28 ROCKWELL ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-4438
Practice Address - Country:US
Practice Address - Phone:617-892-8802
Practice Address - Fax:617-825-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803492Medicaid