Provider Demographics
NPI:1164666996
Name:KENNEBEC VALLEY COMMUNITY ACTION PROGRAM
Entity Type:Organization
Organization Name:KENNEBEC VALLEY COMMUNITY ACTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-859-1565
Mailing Address - Street 1:97 WATER ST
Mailing Address - Street 2:WATERVILLE
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6339
Mailing Address - Country:US
Mailing Address - Phone:207-859-1565
Mailing Address - Fax:
Practice Address - Street 1:97 WATER ST
Practice Address - Street 2:WATERVILLE
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6339
Practice Address - Country:US
Practice Address - Phone:207-859-1565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103990202Medicaid