Provider Demographics
NPI:1376761734
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:508-772-1210
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 1:32 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-4441
Practice Address - Country:US
Practice Address - Phone:508-385-6019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026352HMedicaid