Provider Demographics
NPI:1053467779
Name:PORT RESOURCES
Entity Type:Organization
Organization Name:PORT RESOURCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFREEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-828-0048
Mailing Address - Street 1:280B GANNETT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6940
Mailing Address - Country:US
Mailing Address - Phone:207-828-0048
Mailing Address - Fax:207-772-3743
Practice Address - Street 1:280B GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6940
Practice Address - Country:US
Practice Address - Phone:207-828-0048
Practice Address - Fax:207-772-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME388111320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110580000Medicaid