Healthcare Provider Details

I. General information

NPI: 1861024432
Provider Name (Legal Business Name): ATTLEBORO LODGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MAIN ST
ATTLEBORO MA
02703-4006
US

IV. Provider business mailing address

200 S MAIN ST
ATTLEBORO MA
02703-4006
US

V. Phone/Fax

Practice location:
  • Phone: 781-408-9035
  • Fax: 508-639-5716
Mailing address:
  • Phone: 781-408-9035
  • Fax: 508-639-5716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LOUIS ROSENSPAN
Title or Position: DIRECTOR
Credential:
Phone: 781-408-9035