Provider Demographics
NPI:1134251366
Name:COMMONWEALTH OF MASSACHUSETTS-DMR
Entity type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS-DMR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-624-7577
Mailing Address - Street 1:500 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2439
Mailing Address - Country:US
Mailing Address - Phone:617-727-5608
Mailing Address - Fax:617-624-7577
Practice Address - Street 1:131 EMERALD STREET
Practice Address - Street 2:
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093
Practice Address - Country:US
Practice Address - Phone:508-384-3114
Practice Address - Fax:508-384-1619
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF MASSACHUSETTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-12
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAEXEMPT315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0916315Medicaid