1497810964 NPI number — PEREGRINE CORPORATION

Table of content: (NPI 1497810964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497810964 NPI number — PEREGRINE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEREGRINE CORPORATION
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:
PROJECT FOR SUPPORTED LIVING
Provider Other Organization Name Type Code:
5
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:
1497810964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 FOREST AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-879-0847
Provider Business Mailing Address Fax Number:
207-857-2919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 FOREST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-879-0847
Provider Business Practice Location Address Fax Number:
207-857-2919
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAPCIAK
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
FINANCIAL MANAGER
Authorized Official Telephone Number:
207-879-0847

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 124470100 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470300 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470500 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470001 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470401 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470402 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124470400 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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