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General NPI Number Information
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NPI Number | 1639337280
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Entity Type | Organization
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Legal Business Name | PINE STREET INN, INC.
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 05/30/2008
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Provider Practice Location Address
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Address Line | 28 ROCKWELL ST
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City | DORCHESTER CENTER
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State | MA
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Zip | 02124-4438
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Country | US
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Telephone | 617-892-8802
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Fax | 617-825-9020
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Provider Business Mailing Address
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Address Line | 444 HARRISON AVE
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City | BOSTON
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State | MA
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Zip | 02118-2404
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Country | US
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Telephone | 617-482-4944
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Fax | 617-451-1890
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. TERRENCE B GAGNE
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Credential |
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Telephone | 617-892-9116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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