Provider Demographics
NPI:1750487245
Name:KENNEDY DONOVAN CENTER, INC
Entity Type:Organization
Organization Name:KENNEDY DONOVAN CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODMAN-CONARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-543-2542
Mailing Address - Street 1:1 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2530
Mailing Address - Country:US
Mailing Address - Phone:508-543-2542
Mailing Address - Fax:
Practice Address - Street 1:25 FOREST ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2407
Practice Address - Country:US
Practice Address - Phone:508-226-6035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0008524OtherEARLY INTERVENTION
MAKD0001OtherEARLY INTERVENTION
MA000000021539OtherEARLY INTERVENTION
MA1802453Medicaid
MA1800647Medicaid
MA1800604Medicaid
MA1800612Medicaid
MA601795OtherEARLY INTERVENTION
MAEI0025OtherEARLY INTERVENTION