=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588922991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXODUS HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2012
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 SEAVER ST
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-541-8800
-----------------------------------------------------
Fax | 617-541-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 SEAVER ST
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-541-8800
-----------------------------------------------------
Fax | 617-541-8880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. LOUISA LACOMBE
-----------------------------------------------------
Credential | HEALTH MANAGER
-----------------------------------------------------
Telephone | 617-794-2939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number | 52621
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------