Provider Demographics
NPI:1114168945
Name:ST JUDE'S FOSTER HOME
Entity Type:Organization
Organization Name:ST JUDE'S FOSTER HOME
Other - Org Name:JUDY GAGNON
Other - Org Type:Other Name
Authorized Official - Title/Position:FOSTER HOME OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-868-5180
Mailing Address - Street 1:123 WRIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:VON BUREN
Mailing Address - State:ME
Mailing Address - Zip Code:04785
Mailing Address - Country:US
Mailing Address - Phone:207-868-5180
Mailing Address - Fax:207-868-7781
Practice Address - Street 1:123 WRIGHT STREET
Practice Address - Street 2:
Practice Address - City:VON BUREN
Practice Address - State:ME
Practice Address - Zip Code:04785
Practice Address - Country:US
Practice Address - Phone:207-868-5180
Practice Address - Fax:207-868-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME197470000Medicaid