1477554111 NPI number — FREEPORT NURSING HOME, INC

Table of content: (NPI 1477554111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477554111 NPI number — FREEPORT NURSING HOME, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREEPORT NURSING HOME, 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:
1477554111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 SUMMER ST
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:
04210-5125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-786-0111
Provider Business Mailing Address Fax Number:
207-783-5016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04032-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-786-0111
Provider Business Practice Location Address Fax Number:
207-783-5016
Provider Enumeration Date:
08/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HICKS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-786-0111

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  36218 , 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: 104840000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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