1639203458 NPI number — LYMPHORMATION CENTER

Table of content: (NPI 1639203458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639203458 NPI number — LYMPHORMATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYMPHORMATION CENTER
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:
1639203458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 MAIN ST
Provider Second Line Business Mailing Address:
MARKETPLACE MALL THE COMMONS
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04240-5802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-786-6989
Provider Business Mailing Address Fax Number:
207-786-6990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 MAIN ST
Provider Second Line Business Practice Location Address:
MARKETPLACE MALL THE COMMONS
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04240-5802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-786-6989
Provider Business Practice Location Address Fax Number:
207-786-6990
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATTHEWS
Authorized Official First Name:
DEBRA ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-786-6989

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  OT1547 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: PT2735 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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