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General NPI Number Information
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NPI Number | 1386001105
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Entity Type | Organization
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Legal Business Name | KENNEDY DONOVAN CENTER
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Dates
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Enumeration Date | 01/25/2016
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Last Update Date | 01/25/2016
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Provider Practice Location Address
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Address Line | 486 WORCESTER ST
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City | SOUTHBRIDGE
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State | MA
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Zip | 01550-1386
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Country | US
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Telephone | 508-765-0292
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Fax | 508-765-0294
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Provider Business Mailing Address
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Address Line | 1 COMMERCIAL ST
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City | FOXBORO
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State | MA
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Zip | 02035-2530
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Country | US
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Telephone | 508-772-1230
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Fax | 508-203-8714
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Authorized Official
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Title or Position | CFO
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Name | RICK BORNSTEIN
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Credential | CPA
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Telephone | 508-772-1230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | R32101
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License Number State | MA
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