Healthcare Provider Details

I. General information

NPI: 1780738914
Provider Name (Legal Business Name): ODD FELLOWS HOME OF MASSACHUSETTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 RANDOLPH RD
WORCESTER MA
01606-2465
US

IV. Provider business mailing address

104 RANDOLPH ROAD
WORCESTER MA
01606
US

V. Phone/Fax

Practice location:
  • Phone: 508-853-6687
  • Fax: 508-853-8103
Mailing address:
  • Phone: 508-853-6687
  • Fax: 508-853-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0918
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0998818
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: CLARENCE PLANT
Title or Position: SECRETARY BOARD OF TRUSTEES
Credential:
Phone: 508-853-6687