MEDICARE: MARILLAC RESIDENCE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972630317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARILLAC RESIDENCE, INC

Provider Business Mailing Address
First Line	:	125 OAKLAND ST
Second Line	:
City	:	WELLESLEY HILLS
State	:	MA
Zip	:	02481-5338
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 OAKLAND ST
Second Line	:
City	:	WELLESLEY HILLS
State	:	MA
Zip	:	02481-5338
Country	:	US
Telephone Number	:	781-997-1124
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF FISCAL SERVICES
Name	:	HELEN SHKNEVSKY
Credential	:
Telephone Number	:	781-997-1124

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	08/22/2020

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