MEDICARE: CARDINAL CUSHING CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	TN66483	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083092274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDINAL CUSHING CENTERS, INC.

Provider Business Mailing Address
First Line	:	405 WASHINGTON ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-2343
Country	:	US
Telephone Number	:	781-829-1215
Fax Number	:	781-826-4421

Provider Business Practice Location Address
First Line	:	291 ROCKLAND ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-2385
Country	:	US
Telephone Number	:	781-829-1215
Fax Number	:	781-826-4421

Authorized Official
Title or Position	:	VICE PRESIDENT/CFO
Name	:	MR. SIGMUND ROBERT KOZARYN
Credential	:
Telephone Number	:	781-829-1215

Provider Enumeration Date	:	05/08/2015
Last Update Date	:	05/08/2015

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