Provider Demographics
NPI:1780738914
Name:ODD FELLOWS HOME OF MASSACHUSETTS, INC
Entity type:Organization
Organization Name:ODD FELLOWS HOME OF MASSACHUSETTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY BOARD OF TRUSTEES
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PLANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-853-6687
Mailing Address - Street 1:104 RANDOLPH ROAD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606
Mailing Address - Country:US
Mailing Address - Phone:508-853-6687
Mailing Address - Fax:508-853-8103
Practice Address - Street 1:104 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2465
Practice Address - Country:US
Practice Address - Phone:508-853-6687
Practice Address - Fax:508-853-8103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0918314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0998818Medicaid
MA225439Medicare Oscar/Certification