Provider Demographics
NPI:1891989000
Name:DAVENPORT MEMORIAL FOUNDATION
Entity Type:Organization
Organization Name:DAVENPORT MEMORIAL FOUNDATION
Other - Org Name:DAVENPORT MEMORIAL HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-324-0150
Mailing Address - Street 1:70 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5208
Mailing Address - Country:US
Mailing Address - Phone:781-324-0150
Mailing Address - Fax:781-324-3828
Practice Address - Street 1:70 SALEM ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5208
Practice Address - Country:US
Practice Address - Phone:781-324-0150
Practice Address - Fax:781-324-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1132311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility