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General NPI Number Information
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NPI Number | 1104017961
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Entity Type | Organization
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Legal Business Name | DODGE PARK LLC
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Dates
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Enumeration Date | 08/07/2007
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Last Update Date | 08/07/2007
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Provider Practice Location Address
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Address Line | 101 RANDOLPH RD
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City | WORCESTER
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State | MA
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Zip | 01606-2463
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Country | US
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Telephone | 508-853-8180
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Fax | 508-853-4545
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Provider Business Mailing Address
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Address Line | 101 RANDOLPH RD
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City | WORCESTER
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State | MA
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Zip | 01606-2463
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Country | US
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Telephone | 508-853-8180
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Fax | 508-853-4545
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Authorized Official
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Title or Position | MEMBER/MANAGER
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Name | MR. BEN HERLINGER
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Credential |
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Telephone | 818-571-8972
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 1318
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License Number State | MA
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