Provider Demographics
NPI:1285752394
Name:TOWN OF SOUTHBOROUGH
Entity type:Organization
Organization Name:TOWN OF SOUTHBOROUGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVESQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-486-5115
Mailing Address - Street 1:17 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1663
Mailing Address - Country:US
Mailing Address - Phone:508-486-5115
Mailing Address - Fax:508-486-5123
Practice Address - Street 1:17 COMMON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1663
Practice Address - Country:US
Practice Address - Phone:508-486-5115
Practice Address - Fax:508-486-5123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251300000X251300000X
MA251B00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1950444Medicaid