1912423930 NPI number — 78 SCOTT DYER ROAD OPERATOR LLC

Table of content: MRS. SHERRY ENOCH HOTTENSTEIN MSN RN IBCLC RLC (NPI 1750591681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912423930 NPI number — 78 SCOTT DYER ROAD OPERATOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
78 SCOTT DYER ROAD OPERATOR LLC
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:
6
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:
1912423930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 SCOTT DYER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE ELIZABETH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04107-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-799-7332
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 SCOTT DYER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE ELIZABETH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04107-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-799-7332
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
617-943-7747

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , 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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