Provider Demographics
NPI:1801932165
Name:THE HOME FOR LITTLE WANDERERS
Entity type:Organization
Organization Name:THE HOME FOR LITTLE WANDERERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CORPORATE COMPLIANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-585-7544
Mailing Address - Street 1:271 HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-4506
Mailing Address - Country:US
Mailing Address - Phone:617-267-3700
Mailing Address - Fax:617-428-0441
Practice Address - Street 1:77 BRIGHTON AVE
Practice Address - Street 2:BUILDING #4
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-2109
Practice Address - Country:US
Practice Address - Phone:617-254-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASCDPH36015005191OtherSTATE CONTRACT NUMBER
MA1803182Medicaid