Provider Demographics
NPI:1609160621
Name:MORGANMEMORIAL GOODWILL IND.
Entity type:Organization
Organization Name:MORGANMEMORIAL GOODWILL IND.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICLETA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-541-1274
Mailing Address - Street 1:4137 SCOTTS MILL CT
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-4551
Mailing Address - Country:US
Mailing Address - Phone:781-854-8443
Mailing Address - Fax:
Practice Address - Street 1:4137 SCOTTS MILL CT
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-4551
Practice Address - Country:US
Practice Address - Phone:781-854-8443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0027685700251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA027685700OtherMED CERTIFICATION