Healthcare Provider Details

I. General information

NPI: 1932093523
Provider Name (Legal Business Name): KINCASA RECOVERY CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 W MAIN ST
NORTHBOROUGH MA
01532-1802
US

IV. Provider business mailing address

118 TURNPIKE RD STE 200
SOUTHBOROUGH MA
01772-2156
US

V. Phone/Fax

Practice location:
  • Phone: 603-440-8618
  • Fax:
Mailing address:
  • Phone: 603-440-8618
  • Fax: 323-546-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DENNIS THERIAULT
Title or Position: CEO
Credential:
Phone: 603-440-8618