Provider Demographics
NPI:1700916798
Name:SOUTHBRIDGE PUBLIC SCHOOLS
Entity Type:Organization
Organization Name:SOUTHBRIDGE PUBLIC SCHOOLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-764-5414
Mailing Address - Street 1:41 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-2645
Mailing Address - Country:US
Mailing Address - Phone:508-764-5414
Mailing Address - Fax:
Practice Address - Street 1:41 ELM ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-2645
Practice Address - Country:US
Practice Address - Phone:508-764-5414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1951653Medicaid