Basic Information
| Provider Information | |||||||||
| NPI: | 1063549962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ITALIAN HOME FOR CHILDREN INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175243116 | ||||||||
| FaxNumber: | 8575471138 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175243116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | GLORIEUX | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6175243116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | 4636 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 322D00000X | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 320800000X | 1475185 | MA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 1899929 | 05 | MA | MEDICAID | F47287 | 01 | MA | NETWORK HEALTH | OTHER | 1019890 | 01 | MA | BEACON HEALTH OPTIONS (NOT STRATEGIES) | OTHER | 110032625 | 01 | MA | MASSHEALTH | OTHER |