Provider Demographics
NPI:1003173972
Name:PAT CHANTERELLE LLC
Entity Type:Organization
Organization Name:PAT CHANTERELLE LLC
Other - Org Name:PATRICIA CHANTERELLE, D.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANTERELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-846-7711
Mailing Address - Street 1:30 FOREST FALLS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6983
Mailing Address - Country:US
Mailing Address - Phone:207-846-7711
Mailing Address - Fax:207-846-7711
Practice Address - Street 1:30 FOREST FALLS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6983
Practice Address - Country:US
Practice Address - Phone:207-846-7711
Practice Address - Fax:207-846-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-17
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR601284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4507Medicare PIN