1558760140 NPI number — KENDALL COMMUNITY CASE MANAGEMENT AGENCY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558760140 NPI number — KENDALL COMMUNITY CASE MANAGEMENT AGENCY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENDALL COMMUNITY CASE MANAGEMENT AGENCY
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:
1558760140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 185
Provider Second Line Business Mailing Address:
BERMAN MALL SUITE 3 64 WATER ST
Provider Business Mailing Address City Name:
EASTPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04631-0185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-853-0693
Provider Business Mailing Address Fax Number:
207-853-0694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 WATER ST
Provider Second Line Business Practice Location Address:
BERMAN MALL SUITE 3
Provider Business Practice Location Address City Name:
EASTPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04631-1329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-853-0963
Provider Business Practice Location Address Fax Number:
207-853-0694
Provider Enumeration Date:
08/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KENDALL
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
207-853-4245

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  G9012 HI , 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)





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