Provider Demographics
NPI:1972630317
Name:MARILLAC RESIDENCE, INC
Entity Type:Organization
Organization Name:MARILLAC RESIDENCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FISCAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHKNEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-997-1124
Mailing Address - Street 1:125 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-5338
Practice Address - Country:US
Practice Address - Phone:781-997-1124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5508525Medicaid