1124356191 NPI number — CSD #8

Table of content: (NPI 1124356191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124356191 NPI number — CSD #8

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CSD #8
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:
Provider Other Organization Name Type Code:
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:
1124356191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 KIDDER HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLDEN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04429-6222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-843-0702
Provider Business Mailing Address Fax Number:
207-843-0702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 GREAT POND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04408-7032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-825-3364
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ENMAN
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
207-825-3364

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , 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: 104640000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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