1417280306 NPI number — ODD FELLOWS & REBEKAHS HOME OF MAINE

Table of content: (NPI 1417280306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417280306 NPI number — ODD FELLOWS & REBEKAHS HOME OF MAINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ODD FELLOWS & REBEKAHS HOME OF MAINE
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:
1417280306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 CARON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04210-4288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-786-4616
Provider Business Mailing Address Fax Number:
207-786-4064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 CARON LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-786-4616
Provider Business Practice Location Address Fax Number:
207-786-4064
Provider Enumeration Date:
09/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BERNIER
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
207-786-4616

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  2329 , 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: 102150001 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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