MEDICARE: INTERIM HOUSE 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	324500000X	Substance Abuse Rehabilitation Facility	1697	MA

General Provider Information

NPI Number	:	1508136177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERIM HOUSE INC

Provider Business Mailing Address
First Line	:	62 WALDECK ST
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02124-1329
Country	:	US
Telephone Number	:	617-265-2636
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 WALDECK ST
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02124-1329
Country	:	US
Telephone Number	:	617-265-2636
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MR. ROBERT RALPH MADARUSO
Credential	:	LADC1
Telephone Number	:	617-265-2636

Provider Enumeration Date	:	01/12/2012
Last Update Date	:	01/12/2012

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Directions to “INTERIM HOUSE INC ” Practice Location

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