Provider Demographics
NPI:1841666336
Name:ITALIAN HOME FOR CHILDREN
Entity type:Organization
Organization Name:ITALIAN HOME FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR STAFF ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-524-3116
Mailing Address - Street 1:359 PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-4547
Mailing Address - Country:US
Mailing Address - Phone:617-524-3116
Mailing Address - Fax:
Practice Address - Street 1:1125 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3445
Practice Address - Country:US
Practice Address - Phone:617-524-3116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ITALIAN HOME FOR CHILDREN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1475185251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1922043876Medicaid
MA1063549962Medicaid