Provider Demographics
NPI:1912290081
Name:MARY IMMACULATE ADULT DAY HEALTH II
Entity Type:Organization
Organization Name:MARY IMMACULATE ADULT DAY HEALTH II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-685-6321
Mailing Address - Street 1:172 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:193 MAPLE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-3763
Practice Address - Country:US
Practice Address - Phone:978-682-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY IMMACULATE HEALTH/CARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110032662CMedicaid