1861613879 NPI number — WOODLANDS SENIOR LIVING OF BREWER, LLC

Table of content: (NPI 1861613879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861613879 NPI number — WOODLANDS SENIOR LIVING OF BREWER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODLANDS SENIOR LIVING OF BREWER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WOODLANDS MEMORY CARE OF BREWER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861613879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 W RIVER RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
WATERVILLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04901-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-872-8992
Provider Business Mailing Address Fax Number:
207-861-7072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53 COLONIAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWER
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04412-1448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-989-7577
Provider Business Practice Location Address Fax Number:
207-989-0577
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIROIS
Authorized Official First Name:
JILL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR OF PROFESSIONAL SERVICES
Authorized Official Telephone Number:
207-872-8992

Provider Taxonomy Codes

  • Taxonomy code: 311500000X , with the licence number:  ALLS2646 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ALLS2646 . This is a "LEVEL IV PNMI RCF LICENSE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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