1265554653 NPI number — WOODBREY HAND & PEDIATRIC THERAPY, INC.

Table of content: (NPI 1265554653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265554653 NPI number — WOODBREY HAND & PEDIATRIC THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODBREY HAND & PEDIATRIC THERAPY, INC.
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:
1265554653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 835
Provider Second Line Business Mailing Address:
281 BURLEIGH RD
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-0835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-262-7173
Provider Business Mailing Address Fax Number:
207-947-2465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
281 BURLEIGH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-262-7173
Provider Business Practice Location Address Fax Number:
207-947-2465
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOODBREY JOHNSON
Authorized Official First Name:
BETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-262-7173

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  OT219 , 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: 202200000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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