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General NPI Number Information
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NPI Number | 1508136177
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Entity Type | Organization
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Legal Business Name | INTERIM HOUSE INC
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Dates
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Enumeration Date | 01/12/2012
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Last Update Date | 01/12/2012
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Provider Practice Location Address
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Address Line | 62 WALDECK ST
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City | DORCHESTER
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State | MA
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Zip | 02124-1329
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Country | US
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Telephone | 617-265-2636
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Fax |
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Provider Business Mailing Address
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Address Line | 62 WALDECK ST
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City | DORCHESTER
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State | MA
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Zip | 02124-1329
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Country | US
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Telephone | 617-265-2636
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MR. ROBERT RALPH MADARUSO
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Credential | LADC1
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Telephone | 617-265-2636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 1697
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License Number State | MA
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